Provider Demographics
NPI:1851172902
Name:STEPHAN, KYLE AUGUSTUS
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:AUGUSTUS
Last Name:STEPHAN
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 1:15089 PURCELLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:VA
Mailing Address - Zip Code:20132-3658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3930 WALNUT ST STE 250
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-4750
Practice Address - Country:US
Practice Address - Phone:703-782-3710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09060146931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical