Healthcare Provider Details

I. General information

NPI: 1811548688
Provider Name (Legal Business Name): KAITLYN FARRELLY MS, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

583 SHOEMAKER RD STE 230
KING OF PRUSSIA PA
19406-4238
US

IV. Provider business mailing address

491 ALLENDALE RD STE 201
KING OF PRUSSIA PA
19406-1472
US

V. Phone/Fax

Practice location:
  • Phone: 484-681-2170
  • 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 NumberRBT-18-68032
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: