Provider Demographics
NPI:1114063765
Name:ANDERSON, KYLE CLARK
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:CLARK
Last Name:ANDERSON
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 1:1600 ALDERSGATE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6676
Mailing Address - Country:US
Mailing Address - Phone:501-661-0720
Mailing Address - Fax:
Practice Address - Street 1:500 E MAIN ST
Practice Address - Street 2:SUITE 310
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-4660
Practice Address - Country:US
Practice Address - Phone:870-569-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1608108101Y00000X
AR171M00000X
ARP1810134101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator