Provider Demographics
NPI:1104543602
Name:ROSS, KYLE Y (MA)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:Y
Last Name:ROSS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7950 HENRY AVE APT 18B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-7012
Mailing Address - Country:US
Mailing Address - Phone:484-896-8109
Mailing Address - Fax:
Practice Address - Street 1:234 S BRYN MAWR AVE
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-2133
Practice Address - Country:US
Practice Address - Phone:484-887-8385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health