Provider Demographics
NPI:1932621513
Name:HATTIS, KAILA ROSE
Entity Type:Individual
Prefix:MS
First Name:KAILA
Middle Name:ROSE
Last Name:HATTIS
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 1:501 SOQUEL AVE STE I
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2386
Mailing Address - Country:US
Mailing Address - Phone:831-332-3784
Mailing Address - Fax:
Practice Address - Street 1:9015 MURRAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3617
Practice Address - Country:US
Practice Address - Phone:408-665-4908
Practice Address - Fax:408-842-0383
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA126526106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator