Provider Demographics
NPI:1003432717
Name:EGERDAL, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:EGERDAL
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 1:6709 RAYMOND RD STE 174
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-3943
Mailing Address - Country:US
Mailing Address - Phone:608-205-8587
Mailing Address - Fax:
Practice Address - Street 1:6709 RAYMOND RD STE 174
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-3943
Practice Address - Country:US
Practice Address - Phone:608-205-8587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional