Healthcare Provider Details

I. General information

NPI: 1447929849
Provider Name (Legal Business Name): KYLE STEVEN YACOBEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1536 N BOULDER HWY
HENDERSON NV
89011-4120
US

IV. Provider business mailing address

1200 DREAM BRIDGE DR
LAS VEGAS NV
89144-1616
US

V. Phone/Fax

Practice location:
  • Phone: 702-558-8600
  • Fax:
Mailing address:
  • Phone: 207-522-8525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: