Provider Demographics
NPI:1265538201
Name:WALL, KAYLIE HEATHER (MA,OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KAYLIE
Middle Name:HEATHER
Last Name:WALL
Suffix:
Gender:F
Credentials:MA,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 HYGEIA AVE
Mailing Address - Street 2:#A
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2669
Mailing Address - Country:US
Mailing Address - Phone:760-519-7365
Mailing Address - Fax:
Practice Address - Street 1:551 HYGEIA AVE
Practice Address - Street 2:#A
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2669
Practice Address - Country:US
Practice Address - Phone:760-519-7365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1125225X00000X
NV09-0077225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist