Provider Demographics
NPI:1962137315
Name:HARLEY, CAITLIN M (LCSW)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:M
Last Name:HARLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:M
Other - Last Name:KUTTENKULER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1310 GOODMAN RD E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9542
Mailing Address - Country:US
Mailing Address - Phone:662-470-5433
Mailing Address - Fax:501-745-2378
Practice Address - Street 1:1310 GOODMAN RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9542
Practice Address - Country:US
Practice Address - Phone:662-470-5433
Practice Address - Fax:501-745-2378
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC98671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC9867OtherLCSW LICENSE