Provider Demographics
NPI:1750977344
Name:MCCLURE, KYLA BREANNE
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:BREANNE
Last Name:MCCLURE
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 1:3835 N FREEWAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1954
Mailing Address - Country:US
Mailing Address - Phone:916-576-7900
Mailing Address - Fax:
Practice Address - Street 1:1700 STANDIFORD AVE STE 355
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6534
Practice Address - Country:US
Practice Address - Phone:855-501-1004
Practice Address - Fax:209-661-4673
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA149116106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist