Provider Demographics
NPI:1184931511
Name:HENKEL, KAYLA MARTHA (COTA)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARTHA
Last Name:HENKEL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 LAKEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1327
Mailing Address - Country:US
Mailing Address - Phone:920-428-1260
Mailing Address - Fax:
Practice Address - Street 1:1040 PILGRIM WAY
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5028
Practice Address - Country:US
Practice Address - Phone:920-405-3522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI470327224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant