Provider Demographics
NPI:1528704897
Name:UPSHAW, KAITLYN MARIE (MS, MT-BC, LCAT-LP)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:UPSHAW
Suffix:
Gender:F
Credentials:MS, MT-BC, LCAT-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 EASTBOURNE CRES
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4838
Mailing Address - Country:US
Mailing Address - Phone:631-335-3610
Mailing Address - Fax:
Practice Address - Street 1:135 ENGINEERS RD STE 190
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-4031
Practice Address - Country:US
Practice Address - Phone:631-615-1935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP114930225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP114930OtherCREATIVE ARTS THERAPY - LIMTED PERMIT