Basic Information
| Provider Information | |||||||||
| NPI: | 1891358123 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARY | ||||||||
| FirstName: | KAITLYN | ||||||||
| MiddleName: | NICHOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21600 OXNARD ST | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913674976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183452345 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Practice Location | |||||||||
| Address1: | 12731 MARBLESTONE DR | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221928333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5715890201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2019 | ||||||||
| LastUpdateDate: | 04/22/2019 | ||||||||
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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 | 103K00000X | VA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.