Provider Demographics
NPI:1912470550
Name:SELF, KAYLAN SHANE (MAECSE)
Entity Type:Individual
Prefix:
First Name:KAYLAN
Middle Name:SHANE
Last Name:SELF
Suffix:
Gender:F
Credentials:MAECSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 N SHERMAN ST APT 204
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-2801
Mailing Address - Country:US
Mailing Address - Phone:719-641-4329
Mailing Address - Fax:
Practice Address - Street 1:3425 BLAKE ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2406
Practice Address - Country:US
Practice Address - Phone:719-641-4329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician