Provider Demographics
NPI:1700101540
Name:ADDISON, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:ADDISON
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 1:1058 S 5TH ST
Mailing Address - Street 2:APT. #201
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-6702
Mailing Address - Country:US
Mailing Address - Phone:510-673-2285
Mailing Address - Fax:
Practice Address - Street 1:6630 MARYMONTE CT
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120-4517
Practice Address - Country:US
Practice Address - Phone:408-205-8996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3649322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children