Healthcare Provider Details

I. General information

NPI: 1386459568
Provider Name (Legal Business Name): KYLE REEVE FERNS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 ARNOLD DR STE 200
MARTINEZ CA
94553-4189
US

IV. Provider business mailing address

1340 ARNOLD DR STE 200
MARTINEZ CA
94553-4189
US

V. Phone/Fax

Practice location:
  • Phone: 925-370-5000
  • Fax:
Mailing address:
  • Phone: 707-977-5044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number40385
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: