Provider Demographics
NPI:1619356375
Name:PETERSON, KAYLA MARIE (MS-CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS-CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7227 GOODMAN ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66204-1741
Mailing Address - Country:US
Mailing Address - Phone:913-961-6380
Mailing Address - Fax:
Practice Address - Street 1:7227 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66204-1741
Practice Address - Country:US
Practice Address - Phone:913-961-6380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1761235Z00000X
KS3819235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47065477700Medicaid