=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053130310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAITLYN LAND M.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2024
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1729 NW SAINT LUCIE WEST BLVD # 1276
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-623-8500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10000 SR 78 W
-----------------------------------------------------
City | OKEECHOBEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-623-8500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | IMH2365
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------