Provider Demographics
NPI:1609395672
Name:NIXON, KYLE (PHD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:NIXON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12530 10TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3520
Mailing Address - Country:US
Mailing Address - Phone:909-248-3434
Mailing Address - Fax:909-614-7870
Practice Address - Street 1:12530 10TH ST STE C
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3520
Practice Address - Country:US
Practice Address - Phone:909-248-3434
Practice Address - Fax:909-614-7870
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30919103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY30919OtherBOARD OF PSYCHOLOGY