Provider Demographics
NPI:1114656196
Name:SHAFER, KAYLA (MT)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:SHAFER
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2092 S YANK WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-4311
Mailing Address - Country:US
Mailing Address - Phone:303-253-2223
Mailing Address - Fax:
Practice Address - Street 1:1575 S DECATUR ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80219-4735
Practice Address - Country:US
Practice Address - Phone:970-749-8128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0021442225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COO804464Medicaid