Healthcare Provider Details

I. General information

NPI: 1316870926
Provider Name (Legal Business Name): KAYLA LASS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3263 EATON RD
GREEN BAY WI
54311-6830
US

IV. Provider business mailing address

4517 HEFFRON ST
STEVENS POINT WI
54481-5578
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17757-24
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: