Provider Demographics
NPI:1790460293
Name:IDA, KYLA EILEEN
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:EILEEN
Last Name:IDA
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 1:110 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-1208
Mailing Address - Country:US
Mailing Address - Phone:740-500-1402
Mailing Address - Fax:
Practice Address - Street 1:327 E MILL ST
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-2029
Practice Address - Country:US
Practice Address - Phone:740-500-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.190927101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)