Healthcare Provider Details

I. General information

NPI: 1538464458
Provider Name (Legal Business Name): KAITLYN ANN THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 12/07/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 LONG BEACH BLVD STE 4019
LONG BEACH CA
90807-3315
US

IV. Provider business mailing address

PO BOX 183
ORANGE CA
92856-6183
US

V. Phone/Fax

Practice location:
  • Phone: 562-373-0494
  • Fax:
Mailing address:
  • Phone: 562-373-0494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number112410
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: