Provider Demographics
NPI:1992538375
Name:SPAN, KAYLA MARIE (OTR/L)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:SPAN
Suffix:
Gender:F
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 1:4311 LAKESIDE WAY
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-5612
Mailing Address - Country:US
Mailing Address - Phone:678-777-7643
Mailing Address - Fax:
Practice Address - Street 1:285 SUMMERLIN BLVD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6299
Practice Address - Country:US
Practice Address - Phone:678-990-8918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007871225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist