1407114069 NPI number — KYLE A STEPHENS MAE, BCBA, LBA

Table of content: KYLE A STEPHENS MAE, BCBA, LBA (NPI 1407114069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407114069 NPI number — KYLE A STEPHENS MAE, BCBA, LBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEPHENS
Provider First Name:
KYLE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MAE, BCBA, LBA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407114069
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 516
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBYVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40066-0516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-633-1315
Provider Business Mailing Address Fax Number:
502-633-1316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40065-1026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-633-1315
Provider Business Practice Location Address Fax Number:
502-633-1316
Provider Enumeration Date:
05/01/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100250830 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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