Provider Demographics
NPI:1427085505
Name:KYLE, EDGAR M (PHD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:M
Last Name:KYLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5124 FALCON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-8621
Mailing Address - Country:US
Mailing Address - Phone:540-353-6520
Mailing Address - Fax:
Practice Address - Street 1:5124 FALCON RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-8621
Practice Address - Country:US
Practice Address - Phone:540-353-6520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000932103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007705506Medicaid
VA395223OtherBCBS OF VIRGINIA
VA007710682Medicaid
VA142969OtherBCBS OF VIRGINIA
VA680011123Medicare PIN
VA680001303Medicare PIN
VASC0001031Medicare PIN
VA680001290Medicare PIN
VA007710682Medicaid
VAP00153246Medicare PIN