Provider Demographics
NPI:1063685063
Name:KYLE, MARY SUE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUE
Last Name:KYLE
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 1:1099 FLORIDA AVE S
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2138
Mailing Address - Country:US
Mailing Address - Phone:321-632-6900
Mailing Address - Fax:321-639-7222
Practice Address - Street 1:1099 FLORIDA AVE S
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2138
Practice Address - Country:US
Practice Address - Phone:321-632-6900
Practice Address - Fax:321-639-7222
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY244231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist