Provider Demographics
NPI:1376346411
Name:BISHARAT, KAITLYN DREW (LPC)
Entity type:Individual
Prefix:MRS
First Name:KAITLYN
Middle Name:DREW
Last Name:BISHARAT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 S 1200 W
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-6075
Mailing Address - Country:US
Mailing Address - Phone:208-681-7309
Mailing Address - Fax:
Practice Address - Street 1:495 EMERALD AVE
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-3968
Practice Address - Country:US
Practice Address - Phone:208-932-4545
Practice Address - Fax:208-881-9038
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6861160101Y00000X, 101YP2500X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional