Provider Demographics
NPI:1154884047
Name:DESJARDIN, KAITLYN
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:DESJARDIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CREC-SOUNDBRIDGE
Mailing Address - Street 2:123 PROGRESS DRIVE
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-2450
Mailing Address - Country:US
Mailing Address - Phone:860-529-4260
Mailing Address - Fax:
Practice Address - Street 1:CREC-SOUNDBRIDGE
Practice Address - Street 2:123 PROGRESS DRIVE
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-0610
Practice Address - Country:US
Practice Address - Phone:860-529-4260
Practice Address - Fax:860-257-8500
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000619231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000619OtherLICENSE