Provider Demographics
NPI:1871311795
Name:CUMPSTY-CUMMINGS, KYLIE
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:CUMPSTY-CUMMINGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11247 SAN JOSE BLVD APT 1206
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7270
Mailing Address - Country:US
Mailing Address - Phone:843-789-0600
Mailing Address - Fax:
Practice Address - Street 1:11247 SAN JOSE BLVD APT 1206
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-7270
Practice Address - Country:US
Practice Address - Phone:843-789-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1179101106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician