Healthcare Provider Details

I. General information

NPI: 1003677238
Provider Name (Legal Business Name): KAILYN NYCOL HABERMAN MSW, LSWAIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 SEATTLE HILL RD APT EE3
BOTHELL WA
98012-4104
US

IV. Provider business mailing address

1621 SEATTLE HILL RD APT EE3
BOTHELL WA
98012-4104
US

V. Phone/Fax

Practice location:
  • Phone: 920-728-7089
  • Fax:
Mailing address:
  • Phone: 920-728-7089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC61415382
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: