Provider Demographics
NPI:1912746009
Name:DEITRICK, KAYGEN KAY (LMSW)
Entity type:Individual
Prefix:
First Name:KAYGEN
Middle Name:KAY
Last Name:DEITRICK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3337 KIPLING RD
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-9187
Mailing Address - Country:US
Mailing Address - Phone:319-429-2465
Mailing Address - Fax:
Practice Address - Street 1:2022 3RD AVE NW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2010
Practice Address - Country:US
Practice Address - Phone:319-596-5910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1249751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical