Provider Demographics
NPI:1750004099
Name:WILLIAMS, KAITLIN ALYSE (RADT-1)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ALYSE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:RADT-1
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 586
Mailing Address - Street 2:
Mailing Address - City:CAMINO
Mailing Address - State:CA
Mailing Address - Zip Code:95709-0586
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5494 PONY EXPRESS TRL
Practice Address - Street 2:
Practice Address - City:CAMINO
Practice Address - State:CA
Practice Address - Zip Code:95709-9403
Practice Address - Country:US
Practice Address - Phone:530-644-3758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1483900922101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)