Healthcare Provider Details

I. General information

NPI: 1215553821
Provider Name (Legal Business Name): KAITLYN GRACE BRITTINGHAM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLYN GRACE ROTH

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 S VANN AVE
EVANSVILLE IN
47714-1444
US

IV. Provider business mailing address

PO BOX 33
EVANSVILLE IN
47701-0033
US

V. Phone/Fax

Practice location:
  • Phone: 812-402-8333
  • Fax: 812-402-8331
Mailing address:
  • Phone: 812-402-8333
  • Fax: 812-402-8331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34009878A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: