Provider Demographics
NPI:1558657114
Name:DECKER, KYLE LEE (COTA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:LEE
Last Name:DECKER
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 E TELEGRAPH ST UNIT 81
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-8851
Mailing Address - Country:US
Mailing Address - Phone:210-284-4622
Mailing Address - Fax:
Practice Address - Street 1:504 E TELEGRAPH ST UNIT 81
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-8851
Practice Address - Country:US
Practice Address - Phone:210-284-4622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000877314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility