MEDICARE: MRS. KAYLA LYNNE ANDERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker	149015970	IL

General Provider Information

NPI Number	:	1457453615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KAYLA LYNNE ANDERSON

Provider Business Mailing Address
First Line	:	12 N 64TH ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3809
Country	:	US
Telephone Number	:	618-397-0900
Fax Number	:	618-877-9250

Provider Business Practice Location Address
First Line	:	12 N 64TH ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3809
Country	:	US
Telephone Number	:	618-397-0900
Fax Number	:	618-877-9250

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	11/30/2020

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