Healthcare Provider Details

I. General information

NPI: 1497665749
Provider Name (Legal Business Name): KAYLA PACKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

2535 MILLIKIN PKWY
DECATUR IL
62526-2156
US

IV. Provider business mailing address

1109 3RD ST APT 3
CHARLESTON IL
61920-2789
US

V. Phone/Fax

Practice location:
  • Phone: 217-994-0168
  • Fax:
Mailing address:
  • Phone: 217-994-0168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: