Provider Demographics
NPI:1932567211
Name:KYLE, WADE A (DMIN,M-RAS)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:A
Last Name:KYLE
Suffix:
Gender:M
Credentials:DMIN,M-RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6685 KAISER AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336
Mailing Address - Country:US
Mailing Address - Phone:888-235-3770
Mailing Address - Fax:909-237-0703
Practice Address - Street 1:9774 HAWTHORNE DR.
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:888-235-3770
Practice Address - Fax:909-237-0703
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X, 101YA0400X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral