Provider Demographics
NPI:1851997217
Name:HENGESBACH, CAITLIN ALEXANDRIA
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ALEXANDRIA
Last Name:HENGESBACH
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 1:4262 SAWKAW DR NE APT 202
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1779
Mailing Address - Country:US
Mailing Address - Phone:517-526-2954
Mailing Address - Fax:
Practice Address - Street 1:1919 BOSTON ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4185
Practice Address - Country:US
Practice Address - Phone:616-379-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006684235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist