Provider Demographics
NPI:1598389777
Name:FISKE, KYLE (LCDP)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FISKE
Suffix:
Gender:M
Credentials:LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 BURNETT ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-2527
Mailing Address - Country:US
Mailing Address - Phone:401-785-0050
Mailing Address - Fax:401-941-0089
Practice Address - Street 1:66 BURNETT ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-2527
Practice Address - Country:US
Practice Address - Phone:401-785-0050
Practice Address - Fax:401-941-0089
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI101YA0400X
RICDP00733101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty