Healthcare Provider Details

I. General information

NPI: 1104739002
Provider Name (Legal Business Name): CAITLYN LOTH LMFT- INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 W GRAND AVE STE 240
BELOIT WI
53511-6259
US

IV. Provider business mailing address

136 W GRAND AVE STE 240
BELOIT WI
53511-6259
US

V. Phone/Fax

Practice location:
  • Phone: 608-207-9999
  • Fax: 608-312-2011
Mailing address:
  • Phone: 608-207-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number11036-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: