Provider Demographics
NPI:1396385514
Name:ABRAVAYA, KAITLIN LARISSA (LAC)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:LARISSA
Last Name:ABRAVAYA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11024 E DIAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-7647
Mailing Address - Country:US
Mailing Address - Phone:480-645-1610
Mailing Address - Fax:
Practice Address - Street 1:3635 E INVERNESS AVE STE 109
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3848
Practice Address - Country:US
Practice Address - Phone:480-645-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC18255101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health