Provider Demographics
NPI:1093375370
Name:CLEASBY, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:CLEASBY
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 1:1463 I94 BUSINESS LOOP E
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-6434
Mailing Address - Country:US
Mailing Address - Phone:701-227-7500
Mailing Address - Fax:
Practice Address - Street 1:1919 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2416
Practice Address - Country:US
Practice Address - Phone:701-293-4113
Practice Address - Fax:701-293-4109
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND189902084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry