Provider Demographics
NPI:1083147193
Name:PALMER, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:PALMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-2024
Mailing Address - Country:US
Mailing Address - Phone:774-400-9773
Mailing Address - Fax:
Practice Address - Street 1:3 HILLSIDE AVENUE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-2553
Practice Address - Country:US
Practice Address - Phone:774-400-9773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker