Provider Demographics
NPI:1962077453
Name:BALCOM, KAYLA (PHD)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:BALCOM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 WILLIAMSBURG WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1310
Mailing Address - Country:US
Mailing Address - Phone:208-681-8989
Mailing Address - Fax:
Practice Address - Street 1:2721 WILLIAMSBURG WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1310
Practice Address - Country:US
Practice Address - Phone:208-681-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004384103TC1900X, 103TE1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty