Provider Demographics
NPI:1639659352
Name:MCNUTT, KAITLYNNE ERIN
Entity Type:Individual
Prefix:
First Name:KAITLYNNE
Middle Name:ERIN
Last Name:MCNUTT
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 1:133 DORSET CT APT 16
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5561
Mailing Address - Country:US
Mailing Address - Phone:618-606-6504
Mailing Address - Fax:
Practice Address - Street 1:522 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-2240
Practice Address - Country:US
Practice Address - Phone:618-566-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-18-1398-111311106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician