Healthcare Provider Details

I. General information

NPI: 1598592610
Provider Name (Legal Business Name): KAITLEN VIRGINIA FLYNN MTBC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2024
Last Update Date: 09/14/2024
Certification Date: 09/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1669 W MAPLE RD
BIRMINGHAM MI
48009-1230
US

IV. Provider business mailing address

473 KIRTS BLVD APT 60
TROY MI
48084-5264
US

V. Phone/Fax

Practice location:
  • Phone: 248-646-3347
  • Fax: 248-646-4480
Mailing address:
  • Phone: 630-277-3256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number17845
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: