Provider Demographics
NPI:1285913418
Name:BANDERMANN, KYLE MICHAEL (PHD, MSCP (RXP))
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MICHAEL
Last Name:BANDERMANN
Suffix:
Gender:M
Credentials:PHD, MSCP (RXP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 851 BOX 340
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09834-0004
Mailing Address - Country:US
Mailing Address - Phone:318-439-4169
Mailing Address - Fax:318-439-4169
Practice Address - Street 1:NSA BAHRAIN
Practice Address - Street 2:
Practice Address - City:JUFFAIR
Practice Address - State:BAHRAIN
Practice Address - Zip Code:00000000000342
Practice Address - Country:BH
Practice Address - Phone:318-439-4169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4613103TC0700X
390200000X, 103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program