Provider Demographics
NPI:1972390516
Name:MAXWELL, KAYLA (OTR/L)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2870 N 1825 EAST RD
Mailing Address - Street 2:
Mailing Address - City:BLUE MOUND
Mailing Address - State:IL
Mailing Address - Zip Code:62513-8623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 W IMBODEN DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5238
Practice Address - Country:US
Practice Address - Phone:217-422-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.016060225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist