1487696795 NPI number — DR. MARJORIE TERESA KYLE PSY.D.

Table of content: SOPHIA BURROUGHS (NPI 1780367102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487696795 NPI number — DR. MARJORIE TERESA KYLE PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KYLE
Provider First Name:
MARJORIE
Provider Middle Name:
TERESA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KYLE
Provider Other First Name:
MARJORIE
Provider Other Middle Name:
TERESA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSY.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1487696795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3705 ARCTIC BLVD # 406
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99503-5774
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-230-2190
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4982 ZUKERT AVE
Provider Second Line Business Practice Location Address:
RM 126
Provider Business Practice Location Address City Name:
JBER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-580-0715
Provider Business Practice Location Address Fax Number:
907-580-0629
Provider Enumeration Date:
06/12/2006

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: 103TC2200X , with the licence number:  31369 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X , with the licence number: 628 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1724726 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 628 . This is a "BOARD OF PSYCHOLOGIST" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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