Healthcare Provider Details

I. General information

NPI: 1962366815
Provider Name (Legal Business Name): KAYLA DIANN VINEYARD LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 N HILLSIDE ST
WICHITA KS
67214-4935
US

IV. Provider business mailing address

2208 E QUIVIRA CIR
KECHI KS
67067-8913
US

V. Phone/Fax

Practice location:
  • Phone: 316-550-3066
  • Fax:
Mailing address:
  • Phone: 316-550-3066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number187
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: