Provider Demographics
NPI:1922451343
Name:HAYCRAFT, KAELA (MED, LPC)
Entity Type:Individual
Prefix:
First Name:KAELA
Middle Name:
Last Name:HAYCRAFT
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 NORTHWEST BLVD STE 107A
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2971
Mailing Address - Country:US
Mailing Address - Phone:208-610-3561
Mailing Address - Fax:
Practice Address - Street 1:250 NORTHWEST BLVD STE 107A
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2971
Practice Address - Country:US
Practice Address - Phone:208-610-3561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5729101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional