Provider Demographics
NPI:1750065058
Name:FIELSTRA, MCKAYLA (MS-CF)
Entity type:Individual
Prefix:
First Name:MCKAYLA
Middle Name:
Last Name:FIELSTRA
Suffix:
Gender:F
Credentials:MS-CF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 PROVIDENT DR STE C
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3379
Mailing Address - Country:US
Mailing Address - Phone:574-376-2316
Mailing Address - Fax:
Practice Address - Street 1:902 PROVIDENT DR STE C
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3379
Practice Address - Country:US
Practice Address - Phone:574-376-2316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46004233A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN46004233AOtherSLP-CFY LICENSE NUMBER