Healthcare Provider Details

I. General information

NPI: 1285913418
Provider Name (Legal Business Name): KYLE MICHAEL BANDERMANN PHD, MSCP (RXP)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 06/03/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NSA BAHRAIN
JUFFAIR BAHRAIN
00000000000342
BH

IV. Provider business mailing address

PSC 851 BOX 340
FPO AE
09834-0004
US

V. Phone/Fax

Practice location:
  • Phone: 318-439-4169
  • Fax:
Mailing address:
  • Phone: 318-439-4169
  • Fax: 318-439-4169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4613
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: