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General NPI Number Information
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NPI Number | 1235778549
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Entity Type | Individual
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Provider Name | KYLE PAUL MATERA LCSW
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Gender | Male
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Dates
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Enumeration Date | 01/03/2020
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Last Update Date | 01/03/2020
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Provider Practice Location Address
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Address Line | 110 JOHN F KENNEDY DR STE 118
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City | ATLANTIS
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State | FL
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Zip | 33462-1146
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Country | US
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Telephone | 631-949-7434
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Fax |
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Provider Business Mailing Address
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Address Line | 11211 S MILITARY TRL APT 4221
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City | BOYNTON BEACH
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State | FL
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Zip | 33436-7234
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Country | US
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Telephone | 631-949-7434
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 13960
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License Number State | FL
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