Provider Demographics
NPI:1982771283
Name:KYLLO, CLAIRE OLSEN (LISW)
Entity Type:Individual
Prefix:MS
First Name:CLAIRE
Middle Name:OLSEN
Last Name:KYLLO
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:CLAIRE
Other - Middle Name:ELLEN
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:716 WASHINGTON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-6248
Mailing Address - Country:US
Mailing Address - Phone:505-504-8382
Mailing Address - Fax:
Practice Address - Street 1:716 WASHINGTON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6248
Practice Address - Country:US
Practice Address - Phone:505-504-8382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2015-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1061021041C0700X
NMI-070231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM74908570Medicaid
NM74908570Medicaid