Provider Demographics
NPI:1992350094
Name:SAEPHAN, KAITLYN MAY
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MAY
Last Name:SAEPHAN
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:DEPT LA 22763
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-2763
Mailing Address - Country:US
Mailing Address - Phone:866-523-4268
Mailing Address - Fax:
Practice Address - Street 1:3650 MT DIABLO BLVD STE 107
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3768
Practice Address - Country:US
Practice Address - Phone:866-523-4268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2024-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 390200000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program