Provider Demographics
NPI:1295099844
Name:MATHER, KYLE MICHAEL
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:MICHAEL
Last Name:MATHER
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 1:313 S NAVARRA DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-3647
Mailing Address - Country:US
Mailing Address - Phone:831-818-7476
Mailing Address - Fax:
Practice Address - Street 1:6001 SHELLMOUND ST STE 115
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1924
Practice Address - Country:US
Practice Address - Phone:510-653-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15731225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist