Provider Demographics
NPI:1154023307
Name:WIITALA, KAYLA
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:WIITALA
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 1:800 BROWN ST APT 3
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-3245
Mailing Address - Country:US
Mailing Address - Phone:618-580-0648
Mailing Address - Fax:
Practice Address - Street 1:635 S MAPLE RD UNIT 4
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3838
Practice Address - Country:US
Practice Address - Phone:734-645-8944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851116010101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health