Provider Demographics
NPI:1578997540
Name:BLUE, KAYLAH IMAN
Entity Type:Individual
Prefix:MS
First Name:KAYLAH
Middle Name:IMAN
Last Name:BLUE
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 1:4508 SILVERWIND RD
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-4244
Mailing Address - Country:US
Mailing Address - Phone:702-563-9343
Mailing Address - Fax:
Practice Address - Street 1:570 W CHEYENNE AVE STE 210
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-3983
Practice Address - Country:US
Practice Address - Phone:702-754-3901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst