Provider Demographics
NPI:1255188736
Name:GRASKA, KYLA
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:GRASKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 N CONVENT ST
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1320
Mailing Address - Country:US
Mailing Address - Phone:708-691-1589
Mailing Address - Fax:
Practice Address - Street 1:650 N CONVENT ST
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1320
Practice Address - Country:US
Practice Address - Phone:815-523-7268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician