Healthcare Provider Details

I. General information

NPI: 1730961343
Provider Name (Legal Business Name): KYLA HENDERSON MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KYLA LYLES

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 5TH ST NW
ALBUQUERQUE NM
87102-1302
US

IV. Provider business mailing address

1827 N NATOMA AVE
CHICAGO IL
60707-3919
US

V. Phone/Fax

Practice location:
  • Phone: 312-882-0432
  • Fax:
Mailing address:
  • Phone: 773-495-0695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-1102
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: