Healthcare Provider Details

I. General information

NPI: 1538704374
Provider Name (Legal Business Name): KYLE STOCKMOE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 E SPRINGFIELD AVE STE H
SPOKANE WA
99202-2954
US

IV. Provider business mailing address

1819 E SPRINGFIELD AVE STE H
SPOKANE WA
99202-2954
US

V. Phone/Fax

Practice location:
  • Phone: 509-999-5657
  • Fax:
Mailing address:
  • Phone: 509-999-5657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberAB61253983
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: