Provider Demographics
NPI:1851020002
Name:CLAYCOMB, KYLA DAWN
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:DAWN
Last Name:CLAYCOMB
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 1:427 FAIR AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-1601
Mailing Address - Country:US
Mailing Address - Phone:270-750-1156
Mailing Address - Fax:
Practice Address - Street 1:1518 YORKSHIRE DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9191
Practice Address - Country:US
Practice Address - Phone:270-594-1199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-05
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY256896104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker