Healthcare Provider Details

I. General information

NPI: 1356128912
Provider Name (Legal Business Name): KAYLAH MUNDELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

771 N FREEDOM ST
RAVENNA OH
44266-2470
US

IV. Provider business mailing address

771 N FREEDOM ST
RAVENNA OH
44266-2470
US

V. Phone/Fax

Practice location:
  • Phone: 330-296-5552
  • Fax: 330-296-6126
Mailing address:
  • Phone: 330-296-5552
  • Fax: 330-296-6126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: