Provider Demographics
NPI:1902202237
Name:HERINK, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:HERINK
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 1:6157 SPIETH RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-9469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28 E MARKET ST
Practice Address - Street 2:
Practice Address - City:MARSHALLVILLE
Practice Address - State:OH
Practice Address - Zip Code:44645-9468
Practice Address - Country:US
Practice Address - Phone:330-214-7360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTZ181696171W00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor