Provider Demographics
NPI:1376808311
Name:MCKIBBEN, CAITLYN MARIE
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:MARIE
Last Name:MCKIBBEN
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 1:1710 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SHADY SIDE
Mailing Address - State:MD
Mailing Address - Zip Code:20764-9760
Mailing Address - Country:US
Mailing Address - Phone:443-624-1202
Mailing Address - Fax:
Practice Address - Street 1:8605 CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5265
Practice Address - Country:US
Practice Address - Phone:703-257-6242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist