MEDICARE: MRS. KAYLA SUCHANUK MA, LMHC

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	101YM0800X	Mental Health Counselor	39003740	IN

General Provider Information

NPI Number	:	1790431542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KAYLA SUCHANUK MA, LMHC

Provider Business Mailing Address
First Line	:	1230 W STATE ROAD 2 STE A
Second Line	:
City	:	LA PORTE
State	:	IN
Zip	:	46350-5549
Country	:	US
Telephone Number	:	219-877-5583
Fax Number	:

Provider Business Practice Location Address
First Line	:	1230 W STATE ROAD 2 STE A
Second Line	:
City	:	LA PORTE
State	:	IN
Zip	:	46350-5549
Country	:	US
Telephone Number	:	219-877-5583
Fax Number	:

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

Provider Enumeration Date	:	03/01/2022
Last Update Date	:	03/01/2022

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