Provider Demographics
NPI:1053013334
Name:FATA, MCKAYLA P (MSW, LSW)
Entity type:Individual
Prefix:
First Name:MCKAYLA
Middle Name:P
Last Name:FATA
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:MCKAYLA
Other - Middle Name:
Other - Last Name:SCROGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 E MERCHANTS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543
Mailing Address - Country:US
Mailing Address - Phone:630-428-7890
Mailing Address - Fax:630-428-7891
Practice Address - Street 1:1 E MERCHANTS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543
Practice Address - Country:US
Practice Address - Phone:630-428-7890
Practice Address - Fax:630-428-7891
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1501142861041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health