Healthcare Provider Details

I. General information

NPI: 1568075695
Provider Name (Legal Business Name): KAITLYN JO MUSHRUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLYN JO CONNOR

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 N WOODLAWN BLVD STE 300
WICHITA KS
67220-3960
US

IV. Provider business mailing address

2420 N WOODLAWN BLVD STE 300
WICHITA KS
67220-3960
US

V. Phone/Fax

Practice location:
  • Phone: 316-347-7157
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3003
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number01546
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: