Healthcare Provider Details

I. General information

NPI: 1740597541
Provider Name (Legal Business Name): KYLE VESSELL M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 E CHERYL DR
PHOENIX AZ
85028-4319
US

IV. Provider business mailing address

2625 E CHERYL DR
PHOENIX AZ
85028-4319
US

V. Phone/Fax

Practice location:
  • Phone: 602-493-0172
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3316665
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: