MEDICARE: KYLE GREGORY ISOM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst		CA

General Provider Information

NPI Number	:	1740896638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE GREGORY ISOM

Provider Business Mailing Address
First Line	:	6148 PLYMOUTH AVE
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94805-1206
Country	:	US
Telephone Number	:	707-365-3463
Fax Number	:

Provider Business Practice Location Address
First Line	:	6148 PLYMOUTH AVE
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94805-1206
Country	:	US
Telephone Number	:	707-365-3463
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2020
Last Update Date	:	09/17/2020

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