Provider Demographics
NPI:1356710255
Name:ROBERTS, KYLE GILMORE
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:GILMORE
Last Name:ROBERTS
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 1:15 MYSTIC ST
Mailing Address - Street 2:APT 3
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-1915
Mailing Address - Country:US
Mailing Address - Phone:610-324-7675
Mailing Address - Fax:
Practice Address - Street 1:15 MYSTIC ST
Practice Address - Street 2:APT 3
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-1915
Practice Address - Country:US
Practice Address - Phone:610-324-7675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000689103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst