Provider Demographics
NPI:1760947485
Name:FAIRCLOTH, KYLE BATTAGLIA
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:BATTAGLIA
Last Name:FAIRCLOTH
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 1:558 CLAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-3230
Mailing Address - Country:US
Mailing Address - Phone:510-860-3794
Mailing Address - Fax:
Practice Address - Street 1:1820 SCENIC AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1324
Practice Address - Country:US
Practice Address - Phone:510-548-7270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1328421118101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)