Provider Demographics
NPI:1750798955
Name:DIRKS, KYLA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:DIRKS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:KYLA
Other - Middle Name:NICOLE
Other - Last Name:MERCED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1518 E 3RD ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-3256
Mailing Address - Country:US
Mailing Address - Phone:503-460-7174
Mailing Address - Fax:
Practice Address - Street 1:10315 NE TANASBOURNE DR
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7836
Practice Address - Country:US
Practice Address - Phone:503-495-8513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15277235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1750798955Medicaid