Provider Demographics
NPI:1093420002
Name:GROTH, KYLE
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:
Last Name:GROTH
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 1:7331 WAYFARER DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039-1906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46 S GLEBE RD STE 300
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-1672
Practice Address - Country:US
Practice Address - Phone:703-841-0703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health