Provider Demographics
NPI:1649798695
Name:KOOGLE, KAITLIN MARIE (LSW)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
Last Name:KOOGLE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 COOK RD STE 400
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-9600
Mailing Address - Country:US
Mailing Address - Phone:513-228-7800
Mailing Address - Fax:513-725-2231
Practice Address - Street 1:50 GREENWOOD LN
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066
Practice Address - Country:US
Practice Address - Phone:937-746-1154
Practice Address - Fax:937-746-8523
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.18021251041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical