Provider Demographics
NPI:1225437197
Name:HAGGERTY, KYLE
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:HAGGERTY
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 1:1255 CALDWELL RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-3220
Mailing Address - Country:US
Mailing Address - Phone:853-348-1209
Mailing Address - Fax:856-429-4755
Practice Address - Street 1:201 KINGS HWY S
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2507
Practice Address - Country:US
Practice Address - Phone:856-216-8090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-17
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00533500103G00000X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist