Provider Demographics
NPI:1346062387
Name:MUSTARD, KAITLIN LIANNE (LPT)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:LIANNE
Last Name:MUSTARD
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2460 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1552
Mailing Address - Country:US
Mailing Address - Phone:805-772-2212
Mailing Address - Fax:
Practice Address - Street 1:2460 MAIN ST
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1552
Practice Address - Country:US
Practice Address - Phone:805-235-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37074167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician