Provider Demographics
NPI:1649034315
Name:COLUSSI, KAYLA MARIE
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:COLUSSI
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 1:49023 N 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW RIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85087-8554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3406 W MALDONADO RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6318
Practice Address - Country:US
Practice Address - Phone:480-913-0053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA14622235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist