Provider Demographics
NPI:1093536781
Name:EDWARDS, KAYLA MADISON RAE
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:MADISON RAE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 INLET QUAY APT C
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-9295
Mailing Address - Country:US
Mailing Address - Phone:757-633-4195
Mailing Address - Fax:
Practice Address - Street 1:501 CEDAR RD STE 2A
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-5527
Practice Address - Country:US
Practice Address - Phone:757-302-8362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA07-04017484101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional