Provider Demographics
NPI:1609615046
Name:LIA, KYLE (PEER SPECIALIST)
Entity type:Individual
Prefix:MISS
First Name:KYLE
Middle Name:
Last Name:LIA
Suffix:
Gender:M
Credentials:PEER SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-2403
Mailing Address - Country:US
Mailing Address - Phone:914-761-0600
Mailing Address - Fax:914-737-1050
Practice Address - Street 1:1101 MAIN ST
Practice Address - Street 2:
Practice Address - City:PEEKSKILL
Practice Address - State:NY
Practice Address - Zip Code:10566-2907
Practice Address - Country:US
Practice Address - Phone:914-737-7338
Practice Address - Fax:914-737-1050
Is Sole Proprietor?:No
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYCPS-P-5245175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist