Provider Demographics
NPI:1952912834
Name:CHAMPA, KYLIE
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:CHAMPA
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 1:9163 CYPRESS DR N
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-5290
Mailing Address - Country:US
Mailing Address - Phone:954-495-5614
Mailing Address - Fax:
Practice Address - Street 1:2345 STANFORD CT STE 602
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34112-4841
Practice Address - Country:US
Practice Address - Phone:561-806-1087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty