Provider Demographics
NPI:1235674334
Name:BRANDYBERRY, KYLE (LIMHP, LADC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:BRANDYBERRY
Suffix:
Gender:M
Credentials:LIMHP, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N BAILEY AVE
Mailing Address - Street 2:P.O. BOX 1208
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-5436
Mailing Address - Country:US
Mailing Address - Phone:308-534-0440
Mailing Address - Fax:
Practice Address - Street 1:110 N BAILEY AVE
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5436
Practice Address - Country:US
Practice Address - Phone:308-534-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-1385101YA0400X
NE4849101YM0800X
NE1796101YM0800X
NE1243101YM0800X
NE2319101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional