Provider Demographics
NPI:1790863900
Name:RAQUE, KYLE DAVID (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:DAVID
Last Name:RAQUE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9757 BLUE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-4167
Mailing Address - Country:US
Mailing Address - Phone:706-455-2490
Mailing Address - Fax:706-946-6574
Practice Address - Street 1:9757 BLUE RIDGE DR
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-4167
Practice Address - Country:US
Practice Address - Phone:706-455-2490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003039103TC0700X
NC3256103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000882Medicaid
NC6000882Medicaid