Provider Demographics
NPI:1164192696
Name:WILLARD, KAYLA N
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:N
Last Name:WILLARD
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 1:9 BANKS AVE
Mailing Address - Street 2:
Mailing Address - City:MCADOO
Mailing Address - State:PA
Mailing Address - Zip Code:18237-2508
Mailing Address - Country:US
Mailing Address - Phone:888-726-4774
Mailing Address - Fax:570-362-5112
Practice Address - Street 1:351 TENNY ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-3264
Practice Address - Country:US
Practice Address - Phone:888-726-4474
Practice Address - Fax:570-362-5112
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician