Provider Demographics
NPI:1295329027
Name:TREDWAY, KAITLYNN RENAE (LPC, LMHC)
Entity type:Individual
Prefix:
First Name:KAITLYNN
Middle Name:RENAE
Last Name:TREDWAY
Suffix:
Gender:F
Credentials:LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:NY
Mailing Address - Zip Code:13634-0050
Mailing Address - Country:US
Mailing Address - Phone:269-967-1709
Mailing Address - Fax:
Practice Address - Street 1:19472 US ROUTE 11
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-6897
Practice Address - Country:US
Practice Address - Phone:315-802-3262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004114101YP2500X
NY010123-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional