Provider Demographics
NPI:1255769337
Name:DESUTTER, KAYLA (SLP)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:DESUTTER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 DENMARK DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-4652
Mailing Address - Country:US
Mailing Address - Phone:662-349-2733
Mailing Address - Fax:662-536-1849
Practice Address - Street 1:7160 TCHULAHOMA RD STE B4
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9268
Practice Address - Country:US
Practice Address - Phone:662-349-2733
Practice Address - Fax:662-536-1849
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3759235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSS3759OtherSTATE