Provider Demographics
NPI:1396458436
Name:TISDALE, KAYLA (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:TISDALE
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1928 JOHANNA DR APT 202
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-1960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30330 QUINN RD
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-4300
Practice Address - Country:US
Practice Address - Phone:281-357-3220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20000513982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT9121OtherSTATE LICENSE
TX2000051398OtherBOC CERTIFICATION