Healthcare Provider Details

I. General information

NPI: 1750194486
Provider Name (Legal Business Name): KYLE JORDAN STRUNK TLBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 COLLEGE ST STE D
SOMERSET KY
42501-1307
US

IV. Provider business mailing address

105 COLLEGE ST STE D
SOMERSET KY
42501-1307
US

V. Phone/Fax

Practice location:
  • Phone: 606-677-2636
  • Fax:
Mailing address:
  • Phone: 606-677-2636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number297048
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: