Provider Demographics
NPI:1184441651
Name:CISSELL, KAYLA MARIE
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:CISSELL
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 1:2844 S KENMORE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-5817
Mailing Address - Country:US
Mailing Address - Phone:574-364-8084
Mailing Address - Fax:
Practice Address - Street 1:7105 GALEN DR W
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8450
Practice Address - Country:US
Practice Address - Phone:317-813-4690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-22-224343106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician