Healthcare Provider Details

I. General information

NPI: 1225603152
Provider Name (Legal Business Name): SAMUEL KYSER BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 LYNDON LN
LOUISVILLE KY
40222-3815
US

IV. Provider business mailing address

1230 LIBERTY BANK LN STE 230
LOUISVILLE KY
40222-5756
US

V. Phone/Fax

Practice location:
  • Phone: 502-777-2397
  • Fax: 502-236-1318
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: