Provider Demographics
NPI:1801375340
Name:FREEMAN, KYLE A
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:A
Last Name:FREEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MISCHA
Other - Middle Name:
Other - Last Name:FREEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5263 CLAREMONT AVE UNIT 3
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1032
Mailing Address - Country:US
Mailing Address - Phone:727-417-7155
Mailing Address - Fax:
Practice Address - Street 1:444 34TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2816
Practice Address - Country:US
Practice Address - Phone:510-426-6014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA96062101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program