1871646216 NPI number — MR. KYLE GREGORY CLOUTIER LICSW

Table of content: MR. KYLE GREGORY CLOUTIER LICSW (NPI 1871646216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871646216 NPI number — MR. KYLE GREGORY CLOUTIER LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLOUTIER
Provider First Name:
KYLE
Provider Middle Name:
GREGORY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
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:
1871646216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 240125
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLE VALLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55124-0125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-334-8278
Provider Business Mailing Address Fax Number:
952-891-4258

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 CENTRE POINTE DR STE 100
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
MENDOTA HEIGHTS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55120-1275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-334-8278
Provider Business Practice Location Address Fax Number:
952-891-4258
Provider Enumeration Date:
01/19/2007

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: 1041C0700X , with the licence number:  13976 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 505K6CL . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 114510 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 556368 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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