Provider Demographics
NPI:1811538358
Name:STEVENSON, KAYLA DANIELLE (MS)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:DANIELLE
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 N 53RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1617
Mailing Address - Country:US
Mailing Address - Phone:414-531-6798
Mailing Address - Fax:
Practice Address - Street 1:3090 N 53RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1617
Practice Address - Country:US
Practice Address - Phone:414-531-6798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0731Medicaid