Provider Demographics
NPI:1003536780
Name:MOGG, KAYLA (LLC)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:MOGG
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5396 W SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:SHEPHERD
Mailing Address - State:MI
Mailing Address - Zip Code:48883-9626
Mailing Address - Country:US
Mailing Address - Phone:989-763-7206
Mailing Address - Fax:
Practice Address - Street 1:1714 EASTMAN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4216
Practice Address - Country:US
Practice Address - Phone:989-631-5390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health