Provider Demographics
NPI:1114447893
Name:KACILLAS, KENNA LYNN (OTR/L)
Entity Type:Individual
Prefix:
First Name:KENNA
Middle Name:LYNN
Last Name:KACILLAS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3982 MOUNT FLORA ST
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80549-2207
Mailing Address - Country:US
Mailing Address - Phone:570-436-3718
Mailing Address - Fax:
Practice Address - Street 1:3128 BOXELDER DR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5808
Practice Address - Country:US
Practice Address - Phone:307-634-7901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTR-1208225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist