Provider Demographics
NPI:1487475505
Name:KING, CAITLYN WATTS
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:WATTS
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 1:583 OLD JACKSON RD APT 128
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0380
Mailing Address - Country:US
Mailing Address - Phone:601-201-5385
Mailing Address - Fax:
Practice Address - Street 1:7570 OLD CANTON RD STE 102
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6100
Practice Address - Country:US
Practice Address - Phone:601-809-5324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-1226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health