Healthcare Provider Details

I. General information

NPI: 1760343396
Provider Name (Legal Business Name): KYLE GROW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12816 INGLEWOOD AVE # 1021
HAWTHORNE CA
90250-5118
US

IV. Provider business mailing address

12816 INGLEWOOD AVE # 1021
HAWTHORNE CA
90250-5118
US

V. Phone/Fax

Practice location:
  • Phone: 424-254-9526
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number155442
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: