Provider Demographics
NPI:1740680750
Name:ANDERSON, KAYLEIGH
Entity type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAYLEIGH
Other - Middle Name:
Other - Last Name:DARLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 890
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76703-0890
Mailing Address - Country:US
Mailing Address - Phone:254-752-3451
Mailing Address - Fax:254-756-3133
Practice Address - Street 1:110 S 12TH ST
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701
Practice Address - Country:US
Practice Address - Phone:254-852-3451
Practice Address - Fax:254-756-3133
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2019-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69120101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX338102201Medicaid