Healthcare Provider Details

I. General information

NPI: 1720562101
Provider Name (Legal Business Name): KAITLYN DANGELMAIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 09/28/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 NY-111 SUITE 103
SMITHTOWN NY
11787
US

IV. Provider business mailing address

363 NY-111 SUITE 103
SMITHTOWN NY
11787
US

V. Phone/Fax

Practice location:
  • Phone: 631-265-3133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: