Provider Demographics
NPI:1083410120
Name:PIERSON, KYRIE
Entity type:Individual
Prefix:
First Name:KYRIE
Middle Name:
Last Name:PIERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 RED COACH DR
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-8307
Mailing Address - Country:US
Mailing Address - Phone:574-387-4313
Mailing Address - Fax:
Practice Address - Street 1:10 CORONADO RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46234-2526
Practice Address - Country:US
Practice Address - Phone:574-387-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-24-382256106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician