Healthcare Provider Details

I. General information

NPI: 1861938862
Provider Name (Legal Business Name): KAYLA CARLSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N 18TH ST STE 101
LAFAYETTE IN
47904-3413
US

IV. Provider business mailing address

3511 S 9TH ST
LAFAYETTE IN
47909-3545
US

V. Phone/Fax

Practice location:
  • Phone: 765-423-5361
  • Fax: 765-742-8272
Mailing address:
  • Phone: 765-423-5361
  • Fax: 765-742-8272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number99077229A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: