Provider Demographics
NPI:1972290716
Name:WILSON, KAYLA MICHELLE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MICHELLE
Last Name:WILSON
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 1:829 W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-3304
Mailing Address - Country:US
Mailing Address - Phone:509-954-5458
Mailing Address - Fax:
Practice Address - Street 1:157 S HOWARD ST STE 310
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-4421
Practice Address - Country:US
Practice Address - Phone:509-494-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61417944106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician