Provider Demographics
NPI:1548968472
Name:BUMGARNER, KYLIE
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:BUMGARNER
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 1:46 CENTRAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:HARRINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19952-2257
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 PATRIOT DR STE A
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-8803
Practice Address - Country:US
Practice Address - Phone:302-632-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE106S0000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician