Provider Demographics
NPI:1649904756
Name:KISE, SKYLAR JADE
Entity type:Individual
Prefix:
First Name:SKYLAR
Middle Name:JADE
Last Name:KISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18042-4430
Mailing Address - Country:US
Mailing Address - Phone:484-707-3504
Mailing Address - Fax:
Practice Address - Street 1:1510 VALLEY CENTER PKWY STE 200
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-2267
Practice Address - Country:US
Practice Address - Phone:888-726-4774
Practice Address - Fax:570-362-5112
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician