Provider Demographics
NPI:1366887705
Name:ANDERSON, KAYLYN JANINE
Entity type:Individual
Prefix:MS
First Name:KAYLYN
Middle Name:JANINE
Last Name:ANDERSON
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 1:215 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-2448
Mailing Address - Country:US
Mailing Address - Phone:224-678-9033
Mailing Address - Fax:
Practice Address - Street 1:215 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-2448
Practice Address - Country:US
Practice Address - Phone:224-678-9033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178009616101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty