Provider Demographics
NPI:1861211161
Name:PEARSON, KYLIE
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:PEARSON
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 1:1327 BRIDGECOURT WAY
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-3289
Mailing Address - Country:US
Mailing Address - Phone:406-370-9294
Mailing Address - Fax:
Practice Address - Street 1:2829 GREAT NORTHERN LOOP BSMT LEVEL
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1752
Practice Address - Country:US
Practice Address - Phone:406-579-4984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-72565101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health