Provider Demographics
NPI:1407528136
Name:MCINTOSH, KYLE MICHAEL (LMSW)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:MICHAEL
Last Name:MCINTOSH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4819 41ST ST
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-3121
Mailing Address - Country:US
Mailing Address - Phone:989-574-5854
Mailing Address - Fax:
Practice Address - Street 1:4819 41ST ST
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-3121
Practice Address - Country:US
Practice Address - Phone:989-574-5854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011111651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty