Healthcare Provider Details

I. General information

NPI: 1700718228
Provider Name (Legal Business Name): KAITLIN MITCHELL LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 RIDGEDALE AVE STE 123
CEDAR KNOLLS NJ
07927-1115
US

IV. Provider business mailing address

2 MOUNTAIN AVE
CEDAR KNOLLS NJ
07927-1215
US

V. Phone/Fax

Practice location:
  • Phone: 888-604-6776
  • Fax:
Mailing address:
  • Phone: 973-975-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00949400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: