Provider Demographics
NPI:1962775213
Name:LIDDLE, KYLIE J (MS, LMHC)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:J
Last Name:LIDDLE
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 E WEHNER DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-8601
Mailing Address - Country:US
Mailing Address - Phone:239-896-3194
Mailing Address - Fax:
Practice Address - Street 1:12553 NEW BRITTANY BLVD # 32
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3625
Practice Address - Country:US
Practice Address - Phone:727-490-8513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH16282101YM0800X
IN39004731A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1962775213Medicaid