Healthcare Provider Details

I. General information

NPI: 1669044814
Provider Name (Legal Business Name): KAYLA KIRK CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WILLOW ST
WEST ROXBURY MA
02132-1537
US

IV. Provider business mailing address

25 WILLOW ST
WEST ROXBURY MA
02132-1537
US

V. Phone/Fax

Practice location:
  • Phone: 617-469-3080
  • Fax:
Mailing address:
  • Phone: 617-469-3080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number77614
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: