Provider Demographics
NPI:1003783416
Name:HARRIS, KAITLYN C
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:C
Last Name:HARRIS
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 1:82 ELIZABETH DR
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-1809
Mailing Address - Country:US
Mailing Address - Phone:631-740-1937
Mailing Address - Fax:
Practice Address - Street 1:1235 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-2917
Practice Address - Country:US
Practice Address - Phone:631-345-0083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-21
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist