Healthcare Provider Details

I. General information

NPI: 1457559965
Provider Name (Legal Business Name): MITCHELL BENNETT KAYLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 S CATALINA AVE
REDONDO BEACH CA
90277-4718
US

IV. Provider business mailing address

9808 VENICE BLVD STE 700
CULVER CITY CA
90232-6824
US

V. Phone/Fax

Practice location:
  • Phone: 310-792-5454
  • Fax:
Mailing address:
  • Phone: 310-945-3350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number375170
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: