Healthcare Provider Details

I. General information

NPI: 1104263201
Provider Name (Legal Business Name): KAITLIN RENEE LAMISON MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2013
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 FILLMORE ST
FORT WAYNE IN
46802-5014
US

IV. Provider business mailing address

95 DEVAN AVE
UNIONTOWN PA
15401-4677
US

V. Phone/Fax

Practice location:
  • Phone: 724-317-8489
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: