Provider Demographics
NPI:1275148439
Name:AGATE, KAYTLIN SHINO
Entity Type:Individual
Prefix:
First Name:KAYTLIN
Middle Name:SHINO
Last Name:AGATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 N 400 E APT 105
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-3092
Mailing Address - Country:US
Mailing Address - Phone:206-665-5587
Mailing Address - Fax:
Practice Address - Street 1:445 N 400 E APT 105
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-3092
Practice Address - Country:US
Practice Address - Phone:206-665-5587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-19-93318106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician