Provider Demographics
NPI:1588350045
Name:WAYNTRAUB, KAYLA MICHELLE
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:MICHELLE
Last Name:WAYNTRAUB
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 1:17192 SHERVILLA PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-1931
Mailing Address - Country:US
Mailing Address - Phone:646-467-1807
Mailing Address - Fax:
Practice Address - Street 1:26711 NORTHWESTERN HWY STE 200
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2159
Practice Address - Country:US
Practice Address - Phone:646-467-1807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1070381041C0700X
MI68511111741041C0700X
MI68011163651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical