Provider Demographics
NPI:1497296792
Name:KYLE, JODY L (BCBA, LBA)
Entity Type:Individual
Prefix:MISS
First Name:JODY
Middle Name:L
Last Name:KYLE
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 TROTTER WAY
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-2531
Mailing Address - Country:US
Mailing Address - Phone:636-697-7437
Mailing Address - Fax:314-845-3901
Practice Address - Street 1:14733 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2660
Practice Address - Country:US
Practice Address - Phone:314-339-7732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT-15-08251106S00000X
MO2019003795103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1992256945Medicaid