Provider Demographics
NPI:1790376549
Name:BLOCK, KAYLA (MC, LAC)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:BLOCK
Suffix:
Gender:F
Credentials:MC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 E RAY RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-8720
Mailing Address - Country:US
Mailing Address - Phone:602-427-6302
Mailing Address - Fax:
Practice Address - Street 1:1820 E RAY RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-8720
Practice Address - Country:US
Practice Address - Phone:602-427-6302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-18909101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor