Provider Demographics
NPI:1720537475
Name:BAILEY, KYLE SHANE (BA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:SHANE
Last Name:BAILEY
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1510
Mailing Address - Country:US
Mailing Address - Phone:509-838-4651
Mailing Address - Fax:
Practice Address - Street 1:5901 N LIDGERWOOD ST STE 115
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1122
Practice Address - Country:US
Practice Address - Phone:509-838-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
WACG60713626101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst