Healthcare Provider Details

I. General information

NPI: 1245123306
Provider Name (Legal Business Name): KAYLA MARIE CORNEW LCMHCA, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2025
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5716 FAYETTEVILLE RD
DURHAM NC
27713-9661
US

IV. Provider business mailing address

208 WESTGROVE CT
DURHAM NC
27703-8959
US

V. Phone/Fax

Practice location:
  • Phone: 919-748-4610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA21455
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: