Provider Demographics
NPI:1316650211
Name:WIEDEBUSCH, KAYLA (HIS)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:WIEDEBUSCH
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5303 50TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-1817
Mailing Address - Country:US
Mailing Address - Phone:806-799-8950
Mailing Address - Fax:806-785-4327
Practice Address - Street 1:517 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-1705
Practice Address - Country:US
Practice Address - Phone:325-203-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81008237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist