Provider Demographics
NPI:1750908406
Name:CHANTOS, KYLA JO
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:JO
Last Name:CHANTOS
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 1:2155 MONROE DR
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-7564
Mailing Address - Country:US
Mailing Address - Phone:217-840-1105
Mailing Address - Fax:
Practice Address - Street 1:2155 MONROE DR
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-7564
Practice Address - Country:US
Practice Address - Phone:217-840-1105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist