Provider Demographics
NPI:1619370681
Name:JOHANNSEN, KAITLIN
Entity Type:Individual
Prefix:MRS
First Name:KAITLIN
Middle Name:
Last Name:JOHANNSEN
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 1:15373 INNOVATION DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-3415
Mailing Address - Country:US
Mailing Address - Phone:619-944-8880
Mailing Address - Fax:
Practice Address - Street 1:15373 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3415
Practice Address - Country:US
Practice Address - Phone:619-944-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-9560103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst