Provider Demographics
NPI:1265115380
Name:MCQUEEN, KAYLA GUTIERREZ
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:GUTIERREZ
Last Name:MCQUEEN
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 1:445 E DUBLIN GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-3192
Mailing Address - Country:US
Mailing Address - Phone:614-844-3800
Mailing Address - Fax:
Practice Address - Street 1:28555 STARBRIGHT BLVD
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5662
Practice Address - Country:US
Practice Address - Phone:567-312-4722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHM.2400395-TRNE106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator