Healthcare Provider Details

I. General information

NPI: 1912817339
Provider Name (Legal Business Name): KAYLA SIVESIND
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

1011 LAKE ST STE 307
OAK PARK IL
60301-1138
US

IV. Provider business mailing address

1011 LAKE ST STE 307
OAK PARK IL
60301-1138
US

V. Phone/Fax

Practice location:
  • Phone: 872-395-8091
  • Fax: 773-409-5955
Mailing address:
  • Phone: 872-395-8091
  • Fax: 773-409-5955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071011490
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: