Provider Demographics
NPI:1588288070
Name:HOLLOWAY, KAYLA
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:HOLLOWAY
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 298
Mailing Address - Street 2:
Mailing Address - City:BROOK
Mailing Address - State:IN
Mailing Address - Zip Code:47922-0298
Mailing Address - Country:US
Mailing Address - Phone:219-204-1434
Mailing Address - Fax:
Practice Address - Street 1:216 N 5TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47901-2811
Practice Address - Country:US
Practice Address - Phone:765-423-7988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist