Provider Demographics
NPI:1376317156
Name:WALLER, KAITLIN P (LMHCA)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:P
Last Name:WALLER
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 65221
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-9221
Mailing Address - Country:US
Mailing Address - Phone:831-588-4507
Mailing Address - Fax:
Practice Address - Street 1:19428 AURORA AVE N UNIT 23319428
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-3938
Practice Address - Country:US
Practice Address - Phone:831-588-4507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61201001101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health