Provider Demographics
NPI:1730606443
Name:NEISEN, KAYLA (NCSP, SSP)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:NEISEN
Suffix:
Gender:F
Credentials:NCSP, SSP
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:
Other - Last Name:WINTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NCSP, SSP
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:IL
Mailing Address - Zip Code:62311-0215
Mailing Address - Country:US
Mailing Address - Phone:217-392-2125
Mailing Address - Fax:
Practice Address - Street 1:607 N WORRELL ST
Practice Address - Street 2:
Practice Address - City:BOWEN
Practice Address - State:IL
Practice Address - Zip Code:62316-1048
Practice Address - Country:US
Practice Address - Phone:217-842-5236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL904011103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist