Provider Demographics
NPI:1730675265
Name:BURDETTE, KAITLIN
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:BURDETTE
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 1:10200 FOREST GREEN BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 E MAIN ST STE 210B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-3546
Practice Address - Country:US
Practice Address - Phone:571-419-2892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY262122103K00000X
MDLBA453103K00000X
VA0133001109103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst