Provider Demographics
NPI:1659995553
Name:LONGFELLOW, KAITLIN (CMHC)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:LONGFELLOW
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 S LAKE ERIE DR
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-7350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2655 S LAKE ERIE DR
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84120-7350
Practice Address - Country:US
Practice Address - Phone:385-441-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11758474-6009101YM0800X
UT11758474-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health