Provider Demographics
NPI:1194043562
Name:FAUST, KYLE AARON (PHD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:AARON
Last Name:FAUST
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CONSTITUTION PLZ
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-2025
Mailing Address - Country:US
Mailing Address - Phone:617-724-5202
Mailing Address - Fax:
Practice Address - Street 1:9757 BLUE RIDGE DR
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-4167
Practice Address - Country:US
Practice Address - Phone:310-751-5344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-11
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11303103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist