Healthcare Provider Details

I. General information

NPI: 1659051290
Provider Name (Legal Business Name): KAITLYNN LIGHTHALL RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

23077 GREENFIELD RD STE 430
SOUTHFIELD MI
48075-3748
US

IV. Provider business mailing address

24666 MADISON CT APT 259
FARMINGTON HILLS MI
48335-1849
US

V. Phone/Fax

Practice location:
  • Phone: 248-552-0044
  • Fax: 248-423-7777
Mailing address:
  • Phone: 810-588-3544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: