Provider Demographics
NPI:1982379830
Name:SMITH, KAITLYN (MA, LLP)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8194 KENSINGTON BLVD APT 741
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-3159
Mailing Address - Country:US
Mailing Address - Phone:810-931-2273
Mailing Address - Fax:
Practice Address - Street 1:6060 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3476
Practice Address - Country:US
Practice Address - Phone:248-455-6619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007824103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist