Provider Demographics
NPI:1740640788
Name:SROUR, CAITLYN
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:
Last Name:SROUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10333 E 21ST ST N
Mailing Address - Street 2:204
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3543
Mailing Address - Country:US
Mailing Address - Phone:316-630-8444
Mailing Address - Fax:
Practice Address - Street 1:10333 E 21ST ST N
Practice Address - Street 2:204
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3543
Practice Address - Country:US
Practice Address - Phone:316-630-8444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2729106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201121260AMedicaid