Provider Demographics
NPI:1336022888
Name:WILSON, KAYLA TENNIEL I
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:TENNIEL
Last Name:WILSON
Suffix:I
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 1:20 BANKS ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-6079
Mailing Address - Country:US
Mailing Address - Phone:617-596-1389
Mailing Address - Fax:
Practice Address - Street 1:895 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02124-2902
Practice Address - Country:US
Practice Address - Phone:617-506-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-30
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health