Provider Demographics
NPI:1487204673
Name:NOTTIDGE, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:NOTTIDGE
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 1:10513 SANTA ANITA TER
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-6100
Mailing Address - Country:US
Mailing Address - Phone:240-429-8678
Mailing Address - Fax:
Practice Address - Street 1:10513 SANTA ANITA TER
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:MD
Practice Address - Zip Code:20872-6100
Practice Address - Country:US
Practice Address - Phone:240-429-8678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician