Provider Demographics
NPI:1386248953
Name:SHY, KAYLA DANIELLE
Entity type:Individual
Prefix:MS
First Name:KAYLA
Middle Name:DANIELLE
Last Name:SHY
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:PO BOX 620701
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-0111
Mailing Address - Country:US
Mailing Address - Phone:980-240-6354
Mailing Address - Fax:910-598-8019
Practice Address - Street 1:5804 MONROE RD STE C
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-6183
Practice Address - Country:US
Practice Address - Phone:980-240-6354
Practice Address - Fax:980-598-8019
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 1041C0700X
NC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1235628066OtherGROUP NPI