Basic Information
| Provider Information | |||||||||
| NPI: | 1730680778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUZALSKI | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOSS | ||||||||
| OtherFirstName: | KAITLIN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 330 LAKEVIEW DR | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465289365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745331234 | ||||||||
| FaxNumber: | 5745372652 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 LINCOLNWAY W | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465441626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745331234 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2018 | ||||||||
| LastUpdateDate: | 02/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 33007679A | IN | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.