Basic Information
Provider Information | |||||||||
NPI: | 1487205308 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STURDIVANT | ||||||||
FirstName: | KYNDRA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6201 COLLEYVILLE BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | COLLEYVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 760346236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8179528917 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1901 S MAIN ST | ||||||||
Address2: |   | ||||||||
City: | KELLER | ||||||||
State: | TX | ||||||||
PostalCode: | 762485120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8176913283 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2019 | ||||||||
LastUpdateDate: | 10/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-18-48883 | TX | N |   |   |   |   | 103K00000X | 3766 | TX | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.