Provider Demographics
NPI:1851112015
Name:SREDEN, KYLIE
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:SREDEN
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 1:3002 ARMSTRONG ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5702
Mailing Address - Country:US
Mailing Address - Phone:805-231-9982
Mailing Address - Fax:
Practice Address - Street 1:3002 ARMSTRONG ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-5702
Practice Address - Country:US
Practice Address - Phone:805-231-9982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 171M00000X, 106H00000X, 101YM0800X
CA151450106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health