Provider Demographics
NPI:1013456656
Name:WOELKE, KAITLYN
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:WOELKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:CUBALO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8200 S SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2468
Mailing Address - Country:US
Mailing Address - Phone:810-603-7008
Mailing Address - Fax:
Practice Address - Street 1:9100 LAPEER RD STE C
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-3620
Practice Address - Country:US
Practice Address - Phone:810-653-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009734225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist