Provider Demographics
NPI:1275760852
Name:DITULLIO, KYLE JAMES (CASAC-T)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:JAMES
Last Name:DITULLIO
Suffix:
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12202-1240
Mailing Address - Country:US
Mailing Address - Phone:518-449-5170
Mailing Address - Fax:518-598-0493
Practice Address - Street 1:64 2ND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12202-1240
Practice Address - Country:US
Practice Address - Phone:518-449-5170
Practice Address - Fax:518-598-0493
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22400101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)