Provider Demographics
NPI:1760100770
Name:PETONE, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:PETONE
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:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:LA
Mailing Address - Zip Code:70452-0523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1258 BROWNSWITCH RD STE C
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-1606
Practice Address - Country:US
Practice Address - Phone:985-661-0560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily