Healthcare Provider Details

I. General information

NPI: 1275172629
Provider Name (Legal Business Name): KAITLYN TETREAULT LPC, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 BROAD ST
MANCHESTER CT
06040-4036
US

IV. Provider business mailing address

473 HILLS ST
EAST HARTFORD CT
06118-3048
US

V. Phone/Fax

Practice location:
  • Phone: 860-643-3210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: