Provider Demographics
NPI:1548794324
Name:SOUTHERLAND, CAITLYNN (CTRS)
Entity Type:Individual
Prefix:
First Name:CAITLYNN
Middle Name:
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S. WESTERN AVE
Mailing Address - Street 2:C/O: CREDENTIALING
Mailing Address - City:TONASKET
Mailing Address - State:WA
Mailing Address - Zip Code:98855
Mailing Address - Country:US
Mailing Address - Phone:509-486-3144
Mailing Address - Fax:
Practice Address - Street 1:203 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:TONASKET
Practice Address - State:WA
Practice Address - Zip Code:98855-8803
Practice Address - Country:US
Practice Address - Phone:509-486-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA69003225800000X
WAOT61109008225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60731842OtherWASHINGTON STATE DEPARTMENT OF HEALTH RECREATION THERAPIST REGISTRATION