Provider Demographics
NPI:1750261681
Name:HAGENBACH, KAITLYN GRANT (LCMHCA)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:GRANT
Last Name:HAGENBACH
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5950 FAIRVIEW RD STE 318
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-0088
Mailing Address - Country:US
Mailing Address - Phone:980-263-9433
Mailing Address - Fax:
Practice Address - Street 1:5950 FAIRVIEW RD STE 318
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-0088
Practice Address - Country:US
Practice Address - Phone:980-263-9433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA21436101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health