Healthcare Provider Details

I. General information

NPI: 1770495624
Provider Name (Legal Business Name): KHAYLA T MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E PARK ST STE 106
CHAMPAIGN IL
61820-3862
US

IV. Provider business mailing address

411 E PARK ST STE 106
CHAMPAIGN IL
61820-3862
US

V. Phone/Fax

Practice location:
  • Phone: 217-714-7042
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.112928
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: