Basic Information
| Provider Information | |||||||||
| NPI: | 1093228462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2080 N TUSTIN AVE STE B | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927057875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555810100 | ||||||||
| FaxNumber: | 8553293973 | ||||||||
| Practice Location | |||||||||
| Address1: | 2615 PACIFIC COAST HWY | ||||||||
| Address2: | |||||||||
| City: | HERMOSA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902542225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8332232326 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2017 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | 0-17-7943 | CA | N | 103K00000X | 1-17-28217 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.