Provider Demographics
NPI:1912898198
Name:THIESSEN, KAYLA (LAC)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:THIESSEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 VLIETSTRA DR
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07418-1606
Mailing Address - Country:US
Mailing Address - Phone:973-934-1004
Mailing Address - Fax:
Practice Address - Street 1:15 VLIETSTRA DR
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07418-1606
Practice Address - Country:US
Practice Address - Phone:973-934-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00867900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional