Provider Demographics
NPI:1275321465
Name:EVANS, KYLIN ANNALYSA
Entity type:Individual
Prefix:
First Name:KYLIN
Middle Name:ANNALYSA
Last Name:EVANS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 S PALOUSE ST APT 15
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3376
Mailing Address - Country:US
Mailing Address - Phone:509-778-0237
Mailing Address - Fax:
Practice Address - Street 1:106 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3001
Practice Address - Country:US
Practice Address - Phone:800-781-5536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61669597106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician