Provider Demographics
NPI:1376415216
Name:AMBURGEY, KYLE SAMUEL
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:SAMUEL
Last Name:AMBURGEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 PLANTATION CIR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7990
Mailing Address - Country:US
Mailing Address - Phone:909-567-7901
Mailing Address - Fax:
Practice Address - Street 1:1820 E 17TH ST STE 330
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6400
Practice Address - Country:US
Practice Address - Phone:909-567-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-20
Last Update Date:2025-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician