Provider Demographics
NPI:1750895199
Name:ROUTH, KYLE (LPC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:ROUTH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5295 PAYTON DR W
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-8428
Mailing Address - Country:US
Mailing Address - Phone:601-790-0583
Mailing Address - Fax:
Practice Address - Street 1:7165 GETWELL RD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9618
Practice Address - Country:US
Practice Address - Phone:601-790-0583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1610132101YM0800X
MS2576101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health