Provider Demographics
NPI:1558022806
Name:CARROLL, KAITLIN
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:CARROLL
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 1:6059 RANCHO MISSION RD UNIT 106
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-2369
Mailing Address - Country:US
Mailing Address - Phone:619-206-8706
Mailing Address - Fax:
Practice Address - Street 1:8775 AERO DR STE 333
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1756
Practice Address - Country:US
Practice Address - Phone:858-384-7035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT148004106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist