Provider Demographics
NPI:1790356814
Name:RIDEOUT, KAYLA JEAN
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:JEAN
Last Name:RIDEOUT
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 1:1125 KENT ST APT 10H
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2569
Mailing Address - Country:US
Mailing Address - Phone:740-370-2635
Mailing Address - Fax:
Practice Address - Street 1:196 E EMMITT AVE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1334
Practice Address - Country:US
Practice Address - Phone:740-912-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health