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General NPI Number Information
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NPI Number | 1700101540
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Entity Type | Individual
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Provider Name | KYLE ADDISON
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Gender | Male
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Dates
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Enumeration Date | 04/05/2010
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Last Update Date | 04/05/2010
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Provider Practice Location Address
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Address Line | 6630 MARYMONTE CT
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City | SAN JOSE
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State | CA
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Zip | 95120-4517
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Country | US
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Telephone | 408-205-8996
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Fax |
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Provider Business Mailing Address
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Address Line | 1058 S 5TH ST APT. #201
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City | SAN JOSE
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State | CA
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Zip | 95112-6702
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Country | US
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Telephone | 510-673-2285
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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 | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 3649
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License Number State | CA
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