Provider Demographics
NPI:1659051290
Name:LIGHTHALL, KAITLYNN (RBT)
Entity Type:Individual
Prefix:
First Name:KAITLYNN
Middle Name:
Last Name:LIGHTHALL
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24666 MADISON CT APT 259
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-1849
Mailing Address - Country:US
Mailing Address - Phone:810-588-3544
Mailing Address - Fax:
Practice Address - Street 1:23077 GREENFIELD RD STE 430
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3748
Practice Address - Country:US
Practice Address - Phone:248-552-0044
Practice Address - Fax:248-423-7777
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty