Provider Demographics
NPI:1699921924
Name:FIEDLER, KAITLIN PHELPS (PSYD)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:PHELPS
Last Name:FIEDLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KAITIN
Other - Middle Name:A
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:850 S 5TH ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-3308
Practice Address - Country:US
Practice Address - Phone:610-776-3214
Practice Address - Fax:610-776-3506
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017699103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103563200-0001Medicaid
PA027899OtherINDIVIDUAL MEDICARE
PA027899OtherGROUP MEDICARE