Provider Demographics
NPI:1790227734
Name:KITTLE, TY
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:
Last Name:KITTLE
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 1:7400 GLENLEAF RD LOT 168
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-3718
Mailing Address - Country:US
Mailing Address - Phone:860-307-3399
Mailing Address - Fax:
Practice Address - Street 1:7400 GLENLEAF RD LOT 168
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-3718
Practice Address - Country:US
Practice Address - Phone:860-307-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health