Provider Demographics
NPI:1013587344
Name:PSCODNA, KAITLYN ROSE (MSW, LGSW, RDN, CSSD)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ROSE
Last Name:PSCODNA
Suffix:
Gender:F
Credentials:MSW, LGSW, RDN, CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7052 ABRAHAMSON RD
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-8800
Mailing Address - Country:US
Mailing Address - Phone:612-405-4251
Mailing Address - Fax:
Practice Address - Street 1:7052 ABRAHAMSON RD
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-8800
Practice Address - Country:US
Practice Address - Phone:612-405-4251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN338481041C0700X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN33848OtherLICENSED GRADUATE SOCIAL WORKER