Provider Demographics
NPI:1396105920
Name:BLUE, KAITLIN
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:BLUE
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 1:3025 PASEO VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MARTIN
Mailing Address - State:CA
Mailing Address - Zip Code:95046-9707
Mailing Address - Country:US
Mailing Address - Phone:408-310-0737
Mailing Address - Fax:
Practice Address - Street 1:201 N 1ST ST STE 210
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95113-1003
Practice Address - Country:US
Practice Address - Phone:669-219-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 171M00000X
CAASW1073681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator