Healthcare Provider Details

I. General information

NPI: 1649034315
Provider Name (Legal Business Name): KAYLA MARIE COLUSSI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6635 W HAPPY VALLEY RD STE A104-218
GLENDALE AZ
85310-2609
US

IV. Provider business mailing address

49023 N 25TH AVE
NEW RIVER AZ
85087-8554
US

V. Phone/Fax

Practice location:
  • Phone: 623-224-1214
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP17350
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: