Provider Demographics
NPI:1770854762
Name:RICHETTI, KAITLIN HAFNER (PT)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:HAFNER
Last Name:RICHETTI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:HAFNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2032 NEW CASTLE AVE
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-7703
Practice Address - Country:US
Practice Address - Phone:302-654-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE236027Y0XMedicare PIN