Provider Demographics
NPI:1770152787
Name:KYLES, ANITA RENEE
Entity type:Individual
Prefix:MS
First Name:ANITA
Middle Name:RENEE
Last Name:KYLES
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 1:24534 DUNLAVY CT
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-6371
Mailing Address - Country:US
Mailing Address - Phone:323-423-6200
Mailing Address - Fax:
Practice Address - Street 1:24534 DUNLAVY CT
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-6371
Practice Address - Country:US
Practice Address - Phone:323-423-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty