Provider Demographics
NPI:1790242998
Name:FAASSEN, KAITLIN N
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:N
Last Name:FAASSEN
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 1:5005 MORNING DEW LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-1302
Mailing Address - Country:US
Mailing Address - Phone:980-313-5462
Mailing Address - Fax:
Practice Address - Street 1:5005 MORNING DEW LN
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-1302
Practice Address - Country:US
Practice Address - Phone:980-313-5462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-23
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30456229106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician