Healthcare Provider Details

I. General information

NPI: 1083441125
Provider Name (Legal Business Name): KAYLEE KUTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

854 TECHNOLOGY WAY
LIBERTYVILLE IL
60048-5350
US

IV. Provider business mailing address

854 TECHNOLOGY WAY
LIBERTYVILLE IL
60048-5350
US

V. Phone/Fax

Practice location:
  • Phone: 847-534-7433
  • Fax:
Mailing address:
  • Phone: 847-534-7433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number12475236
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: