Provider Demographics
NPI:1659033884
Name:BURKE, KYLIE NICOLE I (BA)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:NICOLE
Last Name:BURKE
Suffix:I
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 OLDE BAILEY LN
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-8000
Mailing Address - Country:US
Mailing Address - Phone:321-652-3002
Mailing Address - Fax:
Practice Address - Street 1:1887 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5530
Practice Address - Country:US
Practice Address - Phone:772-463-0444
Practice Address - Fax:772-219-1339
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst