Healthcare Provider Details

I. General information

NPI: 1487696795
Provider Name (Legal Business Name): MARJORIE TERESA KYLE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARJORIE TERESA KYLE PSY.D.

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4982 ZUKERT AVE RM 126
JBER AK
99505
US

IV. Provider business mailing address

3705 ARCTIC BLVD # 406
ANCHORAGE AK
99503-5774
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-0715
  • Fax: 907-580-0629
Mailing address:
  • Phone: 607-230-2190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number628
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number31369
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: