Provider Demographics
NPI:1508500703
Name:GORMLEY, KYLER JAMES
Entity Type:Individual
Prefix:
First Name:KYLER
Middle Name:JAMES
Last Name:GORMLEY
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 1:23615 105TH PL SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-3354
Mailing Address - Country:US
Mailing Address - Phone:253-486-5173
Mailing Address - Fax:
Practice Address - Street 1:27023 164TH AVE SE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-8241
Practice Address - Country:US
Practice Address - Phone:253-639-7146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-24
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61294017106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician