Provider Demographics
NPI:1255998746
Name:POULOS, KAYLA (LSW)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:POULOS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1930
Mailing Address - Country:US
Mailing Address - Phone:312-624-8750
Mailing Address - Fax:
Practice Address - Street 1:1 N DEARBORN ST # 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-4331
Practice Address - Country:US
Practice Address - Phone:708-216-0372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
150.102514104100000X
IL149.0225381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker