Provider Demographics
NPI:1487781084
Name:LAURIE, KAITLYN ANN (MS LPC)
Entity type:Individual
Prefix:MS
First Name:KAITLYN
Middle Name:ANN
Last Name:LAURIE
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 MONONA DRIVE
Mailing Address - Street 2:SUITE #312
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716
Mailing Address - Country:US
Mailing Address - Phone:608-839-0435
Mailing Address - Fax:608-839-0435
Practice Address - Street 1:6320 MONONA DRIVE
Practice Address - Street 2:SUITE #312
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716
Practice Address - Country:US
Practice Address - Phone:608-839-0435
Practice Address - Fax:608-839-0435
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1915125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39202500Medicaid