Provider Demographics
NPI:1114454147
Name:HENDERSON, KAYLA RENNE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:RENNE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12008 W US HIGHWAY 60
Mailing Address - Street 2:
Mailing Address - City:OLIVE HILL
Mailing Address - State:KY
Mailing Address - Zip Code:41164-8363
Mailing Address - Country:US
Mailing Address - Phone:270-763-8225
Mailing Address - Fax:270-283-4894
Practice Address - Street 1:12008 W US HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:OLIVE HILL
Practice Address - State:KY
Practice Address - Zip Code:41164-8363
Practice Address - Country:US
Practice Address - Phone:270-763-8225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 222Q00000X
KY201172996222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician