Healthcare Provider Details

I. General information

NPI: 1700476827
Provider Name (Legal Business Name): KYLE VULGAMORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/22/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15221 STATE RT 124
WAVERLY OH
45690-4569
US

IV. Provider business mailing address

84 SUNSET LN
BEAVER OH
45613-9319
US

V. Phone/Fax

Practice location:
  • Phone: 740-493-4260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: