Healthcare Provider Details

I. General information

NPI: 1366746026
Provider Name (Legal Business Name): KYLENE ANN HALLIDAY PSY. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 11/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LINCOLN AVE 364
SAN JOSE CA
95125-3056
US

IV. Provider business mailing address

1100 LINCOLN AVE 364
SAN JOSE CA
95125-3056
US

V. Phone/Fax

Practice location:
  • Phone: 408-915-7365
  • Fax: 888-317-9483
Mailing address:
  • Phone: 408-915-7365
  • Fax: 888-317-9483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY23575
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY23575
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: