Provider Demographics
NPI:1215467410
Name:KYLE, RUSSELL LEE (CRSS, CMMF)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LEE
Last Name:KYLE
Suffix:
Gender:M
Credentials:CRSS, CMMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6709 N RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-6027
Mailing Address - Country:US
Mailing Address - Phone:813-520-2735
Mailing Address - Fax:
Practice Address - Street 1:7207 N NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-4916
Practice Address - Country:US
Practice Address - Phone:813-236-1182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)