Basic Information
| Provider Information | |||||||||
| NPI: | 1942931944 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROTTEAU | ||||||||
| FirstName: | MCKALA | ||||||||
| MiddleName: | KAITLIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 SCHOOL AVE | ||||||||
| Address2: | |||||||||
| City: | CARLTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557184400 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 927 TRETTEL LN | ||||||||
| Address2: | |||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557201345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791227 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2022 | ||||||||
| LastUpdateDate: | 06/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 27661 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.