Provider Demographics
NPI:1447822614
Name:O'NEAL, KAYLA
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:O'NEAL
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:PO BOX 5042
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-5042
Mailing Address - Country:US
Mailing Address - Phone:912-409-7889
Mailing Address - Fax:404-953-6258
Practice Address - Street 1:408 BEDELL AVENUE
Practice Address - Street 2:
Practice Address - City:WOODBINE GA
Practice Address - State:GA
Practice Address - Zip Code:31569
Practice Address - Country:US
Practice Address - Phone:912-409-7889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21169274106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician