Provider Demographics
NPI:1043706500
Name:GOTHAM, KYLE CHRISTOPHER (BA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:CHRISTOPHER
Last Name:GOTHAM
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:287 FENNO ST
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3850
Mailing Address - Country:US
Mailing Address - Phone:857-247-6768
Mailing Address - Fax:
Practice Address - Street 1:43 CHUBB RD
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701-7804
Practice Address - Country:US
Practice Address - Phone:774-270-1766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst