Provider Demographics
NPI:1457025538
Name:LANGWORTHY, KAYLA DIANNE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:DIANNE
Last Name:LANGWORTHY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:DIANNE
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:265 SAN JACINTO RIVER RD STE 107
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:265 SAN JACINTO RIVER RD STE 107
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4400
Practice Address - Country:US
Practice Address - Phone:951-674-9346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health