Provider Demographics
NPI:1902790322
Name:HARRETOS, KAYLA
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:HARRETOS
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 1:19601 PASADENA AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-5611
Mailing Address - Country:US
Mailing Address - Phone:219-742-5294
Mailing Address - Fax:
Practice Address - Street 1:1415 LINCOLNWAY W STE M
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IN
Practice Address - Zip Code:46561-2061
Practice Address - Country:US
Practice Address - Phone:574-675-7767
Practice Address - Fax:574-675-9344
Is Sole Proprietor?:No
Enumeration Date:2025-06-09
Last Update Date:2025-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN14477703235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist