Provider Demographics
NPI:1144787599
Name:CARTER, KAYLA NICOLE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:NICOLE
Last Name:CARTER
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 1:928 S HUMPHREY AVE UNIT 2N
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-2444
Mailing Address - Country:US
Mailing Address - Phone:404-915-8033
Mailing Address - Fax:
Practice Address - Street 1:928 S HUMPHREY AVE UNIT 2N
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-2444
Practice Address - Country:US
Practice Address - Phone:404-915-8033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist