Provider Demographics
NPI:1346096872
Name:MAEDA, KAITLIN M
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:M
Last Name:MAEDA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3767 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-2599
Mailing Address - Country:US
Mailing Address - Phone:619-584-4010
Mailing Address - Fax:619-278-0770
Practice Address - Street 1:3767 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-2599
Practice Address - Country:US
Practice Address - Phone:619-584-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15097101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional