Healthcare Provider Details

I. General information

NPI: 1790460293
Provider Name (Legal Business Name): KYLA EILEEN IDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 E MILL ST
CIRCLEVILLE OH
43113-2029
US

IV. Provider business mailing address

110 HIGHLAND AVE
CIRCLEVILLE OH
43113-1208
US

V. Phone/Fax

Practice location:
  • Phone: 740-500-1402
  • Fax:
Mailing address:
  • Phone: 740-500-1402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2607963
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.163075
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: