Provider Demographics
NPI:1497242929
Name:ELSEA, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:ELSEA
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 1:35 WESTMINSTER ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-3531
Mailing Address - Country:US
Mailing Address - Phone:207-783-0068
Mailing Address - Fax:
Practice Address - Street 1:35 WESTMINSTER ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-3531
Practice Address - Country:US
Practice Address - Phone:207-783-0068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010981341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical