Provider Demographics
NPI:1548728215
Name:CLOSE-STALLWORTH, KAYLA (MA,LLPC)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:CLOSE-STALLWORTH
Suffix:
Gender:F
Credentials:MA,LLPC
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:
Other - Last Name:CLOSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25304 SHIAWASSEE CIR APT 205
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3852
Mailing Address - Country:US
Mailing Address - Phone:313-680-2924
Mailing Address - Fax:
Practice Address - Street 1:29425 NORTHWESTERN HWY STE 210
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1000
Practice Address - Country:US
Practice Address - Phone:248-327-7409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2024-12-10
Deactivation Date:2024-11-29
Deactivation Code:
Reactivation Date:2024-12-10
Provider Licenses
StateLicense IDTaxonomies
MI6451022781101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health