1659051290 NPI number — MRS. KAITLYNN FREDLE BCBA, LBA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659051290 NPI number — MRS. KAITLYNN FREDLE BCBA, LBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREDLE
Provider First Name:
KAITLYNN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCBA, LBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LIGHTHALL
Provider Other First Name:
KAITLYNN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659051290
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30755 BEECHWOOD STREET, APT 45311, WIXOM, MI 48393
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WIXOM
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-588-3544
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21600 NOVI RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NOVI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48375-5605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-305-6172
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-26-90436 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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