Provider Demographics
NPI:1053130310
Name:LAND, KAITLYN (MA)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:LAND
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 SR 78 W
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974
Mailing Address - Country:US
Mailing Address - Phone:863-623-8500
Mailing Address - Fax:
Practice Address - Street 1:1729 NW SAINT LUCIE WEST BLVD # 1276
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2501
Practice Address - Country:US
Practice Address - Phone:863-623-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH2365101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health