Provider Demographics
NPI:1548719883
Name:DOMIN, KAITLYN (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:DOMIN
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:DEBEUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA, LBA
Mailing Address - Street 1:165 KIRTS BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-5214
Mailing Address - Country:US
Mailing Address - Phone:248-486-3636
Mailing Address - Fax:
Practice Address - Street 1:165 KIRTS BLVD STE 500
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-5214
Practice Address - Country:US
Practice Address - Phone:248-486-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401000460103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician