Healthcare Provider Details

I. General information

NPI: 1467331041
Provider Name (Legal Business Name): KYLENE MARIE NEUBERGER SUDRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 M ST
FRESNO CA
93721-1808
US

IV. Provider business mailing address

472 WHITTIER AVE
CLOVIS CA
93611-0636
US

V. Phone/Fax

Practice location:
  • Phone: 559-264-2700
  • Fax:
Mailing address:
  • Phone: 559-326-4997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22336
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: