Provider Demographics
NPI:1457889677
Name:MARTIN, KYLA JO (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KYLA
Middle Name:JO
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:KYLA
Other - Middle Name:JO
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14557 W INDIAN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-9218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14557 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-9218
Practice Address - Country:US
Practice Address - Phone:162-324-2690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6969225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics