Provider Demographics
NPI:1154001089
Name:KYLE, CHARITY ANN
Entity type:Individual
Prefix:
First Name:CHARITY ANN
Middle Name:
Last Name:KYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2540 DOUGLAS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3946
Mailing Address - Country:US
Mailing Address - Phone:916-625-6990
Mailing Address - Fax:
Practice Address - Street 1:2540 DOUGLAS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3946
Practice Address - Country:US
Practice Address - Phone:916-625-6990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139295106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist