Healthcare Provider Details

I. General information

NPI: 1659051290
Provider Name (Legal Business Name): KAITLYNN FREDLE BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAITLYNN LIGHTHALL

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21600 NOVI RD
NOVI MI
48375-5605
US

IV. Provider business mailing address

30755 BEECHWOOD STREET, APT 45311, WIXOM, MI 48393
WIXOM MI
48393
US

V. Phone/Fax

Practice location:
  • Phone: 248-305-6172
  • Fax:
Mailing address:
  • Phone: 810-588-3544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-90436
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: