Provider Demographics
NPI:1578879607
Name:WILLIAMS, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:WILLIAMS
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 1:12322 CLEARGLEN AVE
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90604-3872
Mailing Address - Country:US
Mailing Address - Phone:562-242-1076
Mailing Address - Fax:562-947-4053
Practice Address - Street 1:12322 CLEARGLEN AVE
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90604-3872
Practice Address - Country:US
Practice Address - Phone:562-242-1076
Practice Address - Fax:562-947-4053
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2372287803245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children