Provider Demographics
NPI:1669016077
Name:GANGL, KYLE (BCBA)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:GANGL
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16630 72ND CT NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-6554
Mailing Address - Country:US
Mailing Address - Phone:612-741-3909
Mailing Address - Fax:
Practice Address - Street 1:7001 E FISH LAKE RD STE 200
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-2844
Practice Address - Country:US
Practice Address - Phone:612-260-5022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst