Provider Demographics
NPI:1457453615
Name:ANDERSON, KAYLA LYNNE
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:LYNNE
Last Name:ANDERSON
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 1:12 N 64TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3809
Mailing Address - Country:US
Mailing Address - Phone:618-397-0900
Mailing Address - Fax:618-877-9250
Practice Address - Street 1:12 N 64TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3809
Practice Address - Country:US
Practice Address - Phone:618-397-0900
Practice Address - Fax:618-877-9250
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL1490159701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health