Provider Demographics
NPI:1063935815
Name:BULL, KYLIE MICHELLE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:MICHELLE
Last Name:BULL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 E WINDING CREEK DR STE 120
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7242
Mailing Address - Country:US
Mailing Address - Phone:208-938-4748
Mailing Address - Fax:
Practice Address - Street 1:1409 W MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5215
Practice Address - Country:US
Practice Address - Phone:208-370-5857
Practice Address - Fax:208-506-6312
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-3247235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist