Healthcare Provider Details

I. General information

NPI: 1588139935
Provider Name (Legal Business Name): KAITLYN AYALA LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAITLYN VINES

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date: 05/14/2025
Reactivation Date: 06/10/2025

III. Provider practice location address

5 REVERE DR STE 120
NORTHBROOK IL
60062-8005
US

IV. Provider business mailing address

1365 WILEY RD STE 147
SCHAUMBURG IL
60173-4357
US

V. Phone/Fax

Practice location:
  • Phone: 847-306-9843
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180017051
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178019269
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberNCSP-64737
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: