MEDICARE: KYLA BROEKER WITT MA, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	2002010834	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295874584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLA BROEKER WITT MA, LPC

Provider Business Mailing Address
First Line	:	47 ELLIS AVE
Second Line	:
City	:	TROY
State	:	MO
Zip	:	63379-1151
Country	:	US
Telephone Number	:	636-357-1996
Fax Number	:

Provider Business Practice Location Address
First Line	:	47 ELLIS AVE
Second Line	:
City	:	TROY
State	:	MO
Zip	:	63379-1151
Country	:	US
Telephone Number	:	636-357-1996
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	12/30/2024

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