Provider Demographics
NPI:1245784412
Name:KYLES, MACK III (LPC)
Entity Type:Individual
Prefix:MR
First Name:MACK
Middle Name:
Last Name:KYLES
Suffix:III
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 E STAN SCHLUETER LOOP
Mailing Address - Street 2:SUITE A102
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-4813
Mailing Address - Country:US
Mailing Address - Phone:254-338-4972
Mailing Address - Fax:
Practice Address - Street 1:2904 E STAN SCHLUETER LOOP
Practice Address - Street 2:SUITE A102
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-4813
Practice Address - Country:US
Practice Address - Phone:254-338-4972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72613101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional