Provider Demographics
NPI:1376216127
Name:SLADE, KAITLIN ANNE
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ANNE
Last Name:SLADE
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 1:550 SWEETGRASS LN
Mailing Address - Street 2:
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-4471
Mailing Address - Country:US
Mailing Address - Phone:615-715-8871
Mailing Address - Fax:
Practice Address - Street 1:3900 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23504-1203
Practice Address - Country:US
Practice Address - Phone:757-625-5363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2023-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121781225X00000X
VA0119010202225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist