Provider Demographics
NPI:1770313447
Name:WOOTEN, KAITASHA D
Entity type:Individual
Prefix:
First Name:KAITASHA
Middle Name:D
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAITASHA
Other - Middle Name:DIONNE
Other - Last Name:CRAFT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADCII, MAT, ICADC
Mailing Address - Street 1:1247 JOSEPH E BOONE BLVD NW APT 22
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30314-2360
Mailing Address - Country:US
Mailing Address - Phone:470-905-6046
Mailing Address - Fax:
Practice Address - Street 1:1233 EAGLES LANDING PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6399
Practice Address - Country:US
Practice Address - Phone:404-905-6046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1146101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)