Provider Demographics
NPI:1619595030
Name:STALL, KAITLYN FORET (MOT)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:FORET
Last Name:STALL
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD STE S630
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3194
Mailing Address - Country:US
Mailing Address - Phone:504-340-6976
Mailing Address - Fax:504-934-8044
Practice Address - Street 1:1111 MEDICAL CENTER BLVD STE S630
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3194
Practice Address - Country:US
Practice Address - Phone:504-340-6976
Practice Address - Fax:504-934-8044
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA312458225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist