Basic Information
| Provider Information | |||||||||
| NPI: | 1073951786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHADDICK | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7455 ARROYO CROSSING PKWY STE 220 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891134088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029318990 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3680 N RANCHO DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028694300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2013 | ||||||||
| LastUpdateDate: | 03/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 101YM0800X | CP2985 | NV | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.