Provider Demographics
NPI:1326491549
Name:CORTIS, KYLE JASON
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JASON
Last Name:CORTIS
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 1:22 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-4604
Mailing Address - Country:US
Mailing Address - Phone:413-642-1572
Mailing Address - Fax:413-327-9894
Practice Address - Street 1:280 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-1868
Practice Address - Country:US
Practice Address - Phone:413-642-1672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA12480101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health