Provider Demographics
NPI:1922714039
Name:MACCINI, KYLA MICHELLE
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:MICHELLE
Last Name:MACCINI
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 1:1645 HUNTER RD
Mailing Address - Street 2:
Mailing Address - City:CATAULA
Mailing Address - State:GA
Mailing Address - Zip Code:31804-2405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1645 HUNTER RD
Practice Address - Street 2:
Practice Address - City:CATAULA
Practice Address - State:GA
Practice Address - Zip Code:31804-2405
Practice Address - Country:US
Practice Address - Phone:706-596-5129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW011110104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker