Healthcare Provider Details

I. General information

NPI: 1750292843
Provider Name (Legal Business Name): KAYLA DETIENNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 N NEW BALLAS CT STE 201
CREVE COEUR MO
63141-7174
US

IV. Provider business mailing address

844 N NEW BALLAS CT STE 201
CREVE COEUR MO
63141-7174
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-0444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2026044878
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: