Provider Demographics
NPI:1821859430
Name:WALLACE, KAITLYN (LPC-MHSP)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:BELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC-MHSP
Mailing Address - Street 1:1360 MACKEY BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1360 MACKEY BRANCH DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3225
Practice Address - Country:US
Practice Address - Phone:423-443-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6374101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional