Provider Demographics
NPI:1215430830
Name:GREVIOUS, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:GREVIOUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 BLUEBONNET BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-9661
Mailing Address - Country:US
Mailing Address - Phone:225-223-6968
Mailing Address - Fax:225-442-1396
Practice Address - Street 1:4315 BLUEBONNET BLVD STE B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-9661
Practice Address - Country:US
Practice Address - Phone:225-223-6968
Practice Address - Fax:225-442-1396
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty