Provider Demographics
NPI:1699536284
Name:WILLIS, KAYLA CHANNEL
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:CHANNEL
Last Name:WILLIS
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 1:3395 LUXEMBOURG CIR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-5418
Mailing Address - Country:US
Mailing Address - Phone:678-914-4590
Mailing Address - Fax:
Practice Address - Street 1:3395 LUXEMBOURG CIR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-5418
Practice Address - Country:US
Practice Address - Phone:678-914-4590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor