Provider Demographics
NPI:1164038519
Name:VAN CLEVE, KYLIE (LMT)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:VAN CLEVE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34626 SE SWENSON DR APT D107
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-5112
Mailing Address - Country:US
Mailing Address - Phone:385-414-7336
Mailing Address - Fax:
Practice Address - Street 1:1320 NW MALL ST STE A2
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-8964
Practice Address - Country:US
Practice Address - Phone:425-557-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61090457225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist