Basic Information
| Provider Information | |||||||||
| NPI: | 1265954796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORE-HALL | ||||||||
| FirstName: | KYLIE | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MS, LPA, LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GORE | ||||||||
| OtherFirstName: | KYLIE | ||||||||
| OtherMiddleName: | RAE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 530 7TH AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074518208 | ||||||||
| FaxNumber: | 9074518207 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 7TH AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074518208 | ||||||||
| FaxNumber: | 9074518207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2017 | ||||||||
| LastUpdateDate: | 01/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | 157795 | AK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.