=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437020393
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAITLYN MARIE ROBERTS
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2025
-----------------------------------------------------
Last Update Date | 09/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6000 S 1075 E
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84405-4945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-429-9906
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2909 STONEWOOD ST NW
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49504-8003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-822-2121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 14240762-3502
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------