Provider Demographics
NPI:1316445000
Name:SZELAG, KYLA M
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:M
Last Name:SZELAG
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 1:2007 NE ZACHARY CT APT 2
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-5327
Mailing Address - Country:US
Mailing Address - Phone:541-771-9140
Mailing Address - Fax:
Practice Address - Street 1:19800 VILLAGE OFFICE CT STE 104
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1813
Practice Address - Country:US
Practice Address - Phone:541-480-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-27
Last Update Date:2018-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1942537444Medicaid