Healthcare Provider Details

I. General information

NPI: 1104595446
Provider Name (Legal Business Name): KYLA L GILMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5815 STODDARD RD STE 600
MODESTO CA
95356-9041
US

IV. Provider business mailing address

5727 SUTTER AVE APT 6
CARMICHAEL CA
95608-2376
US

V. Phone/Fax

Practice location:
  • Phone: 209-543-1874
  • Fax:
Mailing address:
  • Phone: 97-614-9192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number99050
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number99050
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: