Provider Demographics
NPI:1699492827
Name:KENNEDY, KYLE
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:KENNEDY
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 1:1422 CENTENNIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-0439
Mailing Address - Country:US
Mailing Address - Phone:317-874-8799
Mailing Address - Fax:
Practice Address - Street 1:6603 OAK HILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-0586
Practice Address - Country:US
Practice Address - Phone:903-213-2203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33675103TC0700X
TX39561103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical