Provider Demographics
NPI:1952902579
Name:GALL, KAITLYN MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KAITLYN
Middle Name:MARIE
Last Name:GALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 E KIEHL AVE APT 8001
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-3562
Mailing Address - Country:US
Mailing Address - Phone:847-209-7711
Mailing Address - Fax:
Practice Address - Street 1:6020 WARDEN RD STE 210
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-6015
Practice Address - Country:US
Practice Address - Phone:501-537-1388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY276735103G00000X
103T00000X, 103TH0100X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty