Provider Demographics
NPI:1396362547
Name:MATHESON, KAYLA M
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:M
Last Name:MATHESON
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:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:TRIUMPH
Mailing Address - State:IL
Mailing Address - Zip Code:61371-0002
Mailing Address - Country:US
Mailing Address - Phone:815-503-1481
Mailing Address - Fax:
Practice Address - Street 1:2013 4TH ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-3208
Practice Address - Country:US
Practice Address - Phone:815-414-0905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227018699225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist