Provider Demographics
NPI:1164236303
Name:POOLE, KAYLIE M
Entity type:Individual
Prefix:
First Name:KAYLIE
Middle Name:M
Last Name:POOLE
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 1:685 E CYPRESS AVE APT A
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-5340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11799 SEBASTIAN WAY STE 103
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0708
Practice Address - Country:US
Practice Address - Phone:951-420-7130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician