Provider Demographics
NPI:1902219355
Name:POTTENGER, KYLIE KRISTEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KYLIE
Middle Name:KRISTEN
Last Name:POTTENGER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:1423 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-1917
Practice Address - Country:US
Practice Address - Phone:417-269-7728
Practice Address - Fax:417-269-7729
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013042520103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical