Healthcare Provider Details

I. General information

NPI: 1982243879
Provider Name (Legal Business Name): KAYLA IMANI EDING LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/25/2019
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2833 CHARIOT LN
OLYMPIA FIELDS IL
60461-1512
US

IV. Provider business mailing address

2833 CHARIOT LN
OLYMPIA FIELDS IL
60461-1512
US

V. Phone/Fax

Practice location:
  • Phone: 616-566-0770
  • Fax:
Mailing address:
  • Phone: 616-566-0770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904019977
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: