Provider Demographics
NPI:1669769766
Name:CONNOR, KYLA
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:CONNOR
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 1:6 SYLVAN LN
Mailing Address - Street 2:
Mailing Address - City:BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01505-1434
Mailing Address - Country:US
Mailing Address - Phone:508-498-6441
Mailing Address - Fax:
Practice Address - Street 1:96 W MAIN ST STE E1
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-3810
Practice Address - Country:US
Practice Address - Phone:508-422-0024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-09
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9384101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program