MEDICARE: MRS. KAITLIN WOSTENBERG BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst	1-20-41400

General Provider Information

NPI Number	:	1104324300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KAITLIN WOSTENBERG BCBA

Provider Business Mailing Address
First Line	:	1114 E 29TH ST
Second Line	:
City	:	DAVENPORT
State	:	IA
Zip	:	52803-1902
Country	:	US
Telephone Number	:	307-421-3618
Fax Number	:

Provider Business Practice Location Address
First Line	:	1114 E 29TH ST
Second Line	:
City	:	DAVENPORT
State	:	IA
Zip	:	52803-1902
Country	:	US
Telephone Number	:	307-421-3618
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2018
Last Update Date	:	06/06/2023

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