Provider Demographics
NPI:1295874584
Name:BROEKER WITT, KYLA (MA, LPC)
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:BROEKER WITT
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1151
Mailing Address - Country:US
Mailing Address - Phone:636-357-1996
Mailing Address - Fax:
Practice Address - Street 1:47 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1151
Practice Address - Country:US
Practice Address - Phone:636-357-1996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002010834101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495771313Medicaid