Healthcare Provider Details

I. General information

NPI: 1750859948
Provider Name (Legal Business Name): KYLA CARLSON QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 E COLLEGE ST
KEWANEE IL
61443-3703
US

IV. Provider business mailing address

137 E COLLEGE ST
KEWANEE IL
61443-3703
US

V. Phone/Fax

Practice location:
  • Phone: 309-852-4331
  • Fax: 309-854-0122
Mailing address:
  • Phone: 309-852-4331
  • Fax: 309-854-0122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: