Basic Information
| Provider Information | |||||||||
| NPI: | 1326007634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALDRIP | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 660 | ||||||||
| Address2: | 301 RANDOLPH ST | ||||||||
| City: | DENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104794306 | ||||||||
| FaxNumber: | 4104791714 | ||||||||
| Practice Location | |||||||||
| Address1: | 1013 TALBOT ST | ||||||||
| Address2: | UNIT L | ||||||||
| City: | ST MICHAELS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107455020 | ||||||||
| FaxNumber: | 4107450492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 08/03/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 06847 | MD | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.