Basic Information
| Provider Information | |||||||||
| NPI: | 1336216977 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KITAJI | ||||||||
| FirstName: | KAILYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2577 NE COURTNEY DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413227500 | ||||||||
| FaxNumber: | 5413227565 | ||||||||
| Practice Location | |||||||||
| Address1: | 1314 SW KALAMA AVE | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977563054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413227500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 03/25/2018 | ||||||||
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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 | 1041C0700X | L6563 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | ASW 28762 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 41933 | 01 | CA | UNICARE NUMBER | OTHER |