Healthcare Provider Details

I. General information

NPI: 1801662440
Provider Name (Legal Business Name): KYSA TWYLA BALTIMORE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2733
US

IV. Provider business mailing address

100 BENT TREE DR APT 93
DAYTONA BEACH FL
32114-1174
US

V. Phone/Fax

Practice location:
  • Phone: 386-676-7175
  • Fax: 386-676-6134
Mailing address:
  • Phone: 347-407-2453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number22946
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: