Basic Information
| Provider Information | |||||||||
| NPI: | 1457014367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHESTER | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 174 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CLARKSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263012918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595337556 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 53 DON KNOTTS BLVD | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265086838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042840025 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2021 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.