Healthcare Provider Details

I. General information

NPI: 1699618751
Provider Name (Legal Business Name): KAILYN ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GEORGE RED BIRD DR SE
MASSILLON OH
44646-7104
US

IV. Provider business mailing address

400 GEORGE RED BIRD DR SE
MASSILLON OH
44646-7104
US

V. Phone/Fax

Practice location:
  • Phone: 330-830-3903
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.03154
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: