Provider Demographics
NPI:1831599612
Name:IVORY, KYLEIGH (MED BSL)
Entity type:Individual
Prefix:
First Name:KYLEIGH
Middle Name:
Last Name:IVORY
Suffix:
Gender:F
Credentials:MED BSL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLEETWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19522-1323
Mailing Address - Country:US
Mailing Address - Phone:610-944-0445
Mailing Address - Fax:
Practice Address - Street 1:90 S COMMERCE WAY
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-8601
Practice Address - Country:US
Practice Address - Phone:610-691-8401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002392103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA23-2052170OtherCONCERN COUNSELING SERVICES FOR CHILDREN YOUTH AND FAMILIES