Healthcare Provider Details

I. General information

NPI: 1063984805
Provider Name (Legal Business Name): KYLIE R HORNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W 58TH ST STE 409
NEW YORK NY
10019
US

IV. Provider business mailing address

42 DRIGGS AVE APT 3C
BROOKLYN NY
11222-4524
US

V. Phone/Fax

Practice location:
  • Phone: 212-877-5500
  • Fax:
Mailing address:
  • Phone: 856-381-8485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number103951-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: