Healthcare Provider Details

I. General information

NPI: 1245172923
Provider Name (Legal Business Name): KAYLA SHANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 BONHOMME AVE STE 201
SAINT LOUIS MO
63105-3515
US

IV. Provider business mailing address

245 UNION BLVD APT 401
SAINT LOUIS MO
63108-1292
US

V. Phone/Fax

Practice location:
  • Phone: 812-470-7650
  • Fax:
Mailing address:
  • Phone: 812-470-7650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2026007828
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: