Provider Demographics
NPI:1710759220
Name:DESILETS, KAYLA MARIE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:DESILETS
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 1:8012 BRANDON ST APT 8012
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-7877
Mailing Address - Country:US
Mailing Address - Phone:470-693-3203
Mailing Address - Fax:
Practice Address - Street 1:107 WEATHERSTONE DR STE 530
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-7006
Practice Address - Country:US
Practice Address - Phone:177-059-1955
Practice Address - Fax:800-218-8249
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GANONE106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician