Provider Demographics
NPI:1336800192
Name:KYLE, COURTNEY LEE
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEE
Last Name:KYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LEE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:306 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2533
Mailing Address - Country:US
Mailing Address - Phone:912-294-4055
Mailing Address - Fax:
Practice Address - Street 1:306 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2533
Practice Address - Country:US
Practice Address - Phone:912-294-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-198290106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician