Provider Demographics
NPI:1689432759
Name:PETTY, KAYLA SUANN
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:SUANN
Last Name:PETTY
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 1:4688 E MAJESTIC VIEW DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406-8180
Mailing Address - Country:US
Mailing Address - Phone:580-522-1119
Mailing Address - Fax:
Practice Address - Street 1:4688 E MAJESTIC VIEW DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83406-8180
Practice Address - Country:US
Practice Address - Phone:580-522-1119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCOUI-10305101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health