Provider Demographics
NPI:1710658513
Name:PUFFENBERGER, KYLE GRAVES
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:GRAVES
Last Name:PUFFENBERGER
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 1:6849 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-1608
Mailing Address - Country:US
Mailing Address - Phone:678-691-2206
Mailing Address - Fax:
Practice Address - Street 1:6849 PEACHTREE DUNWOODY RD BLDG A1
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-6769
Practice Address - Country:US
Practice Address - Phone:678-691-2206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-147581106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARBT-20-147581OtherBEHAVIOR TECHNICIAN