Provider Demographics
NPI:1730680778
Name:BUZALSKI, KAITLIN (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:BUZALSKI
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:
Other - Last Name:BOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:330 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-9365
Mailing Address - Country:US
Mailing Address - Phone:574-533-1234
Mailing Address - Fax:574-537-2652
Practice Address - Street 1:1411 LINCOLNWAY W
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1626
Practice Address - Country:US
Practice Address - Phone:574-533-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33007679A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor