Provider Demographics
NPI:1720586878
Name:PYRTLE, KIERSTEN
Entity type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:
Last Name:PYRTLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 ED SWIFT RD
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-5638
Mailing Address - Country:US
Mailing Address - Phone:757-871-5122
Mailing Address - Fax:
Practice Address - Street 1:302 SOUTHARD ST STE 106
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-8404
Practice Address - Country:US
Practice Address - Phone:757-871-5122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1720586878103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022786000Medicaid