Provider Demographics
NPI:1528800711
Name:LAWSON, KYLE JUSTIN
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JUSTIN
Last Name:LAWSON
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 1:3210 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-1614
Mailing Address - Country:US
Mailing Address - Phone:661-754-4542
Mailing Address - Fax:
Practice Address - Street 1:1315 FRUITVALE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2927
Practice Address - Country:US
Practice Address - Phone:510-300-3170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15977101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)