Provider Demographics
NPI:1285172916
Name:KING, KAITLYN IRENE-LEE
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:IRENE-LEE
Last Name:KING
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 1:106 ROSE ST
Mailing Address - Street 2:PO BOX 183
Mailing Address - City:ROSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48654-9441
Mailing Address - Country:US
Mailing Address - Phone:989-709-6745
Mailing Address - Fax:
Practice Address - Street 1:106 ROSE ST
Practice Address - Street 2:
Practice Address - City:ROSE CITY
Practice Address - State:MI
Practice Address - Zip Code:48654-9441
Practice Address - Country:US
Practice Address - Phone:989-709-6745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician