Healthcare Provider Details

I. General information

NPI: 1760031561
Provider Name (Legal Business Name): KAITLYN MARIE MAGUIRE LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 FRONT ST
CHICOPEE MA
01020-1722
US

IV. Provider business mailing address

63 BLUEBERRY HILL ST
SPRINGFIELD MA
01128-1011
US

V. Phone/Fax

Practice location:
  • Phone: 413-594-3437
  • Fax:
Mailing address:
  • Phone: 978-987-4478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3588
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: