Provider Demographics
NPI:1215283205
Name:CARRILLO, KAYLA JO (MOT, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:JO
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:MISS
Other - First Name:KAYLA
Other - Middle Name:JO
Other - Last Name:CLANTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT,OTR/L
Mailing Address - Street 1:7912 RASPBERRY SWIRL RD
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-7423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 W MASON ST STE B
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076-1262
Practice Address - Country:US
Practice Address - Phone:417-848-2262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050335768225200000X
MO2012023105225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant