Provider Demographics
NPI:1912403429
Name:GUNDLING-CHILDS, KYLE ELIZABETH
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ELIZABETH
Last Name:GUNDLING-CHILDS
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 1:31 BELLA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-7097
Mailing Address - Country:US
Mailing Address - Phone:505-450-9340
Mailing Address - Fax:
Practice Address - Street 1:31 BELLA VISTA RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-7097
Practice Address - Country:US
Practice Address - Phone:505-450-9340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1-20-43159103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst