Healthcare Provider Details

I. General information

NPI: 1104145507
Provider Name (Legal Business Name): KAYLA S FANGUY LPC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 AMBASSADOR CAFFERY PKWY BLDG. D, SUITE B-220
LAFAYETTE LA
70508-6928
US

IV. Provider business mailing address

4540 AMBASSADOR CAFFERY PKWY BLDG. D, SUITE B-220
LAFAYETTE LA
70508-6928
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-2180
  • Fax: 337-981-2391
Mailing address:
  • Phone: 337-981-2180
  • Fax: 337-981-2391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3986
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1129
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: