Provider Demographics
NPI:1902433493
Name:HALLWYLER, KAITLYN MAE (LBSW)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MAE
Last Name:HALLWYLER
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 S MELENDRES ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2932
Mailing Address - Country:US
Mailing Address - Phone:313-405-8915
Mailing Address - Fax:
Practice Address - Street 1:2884 N ROADRUNNER PKWY
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-0853
Practice Address - Country:US
Practice Address - Phone:575-556-6115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-11430104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMX-11430OtherPROVISIONAL BACCALAUREATE SOCIAL WORK LICENSURE