Basic Information
| Provider Information | |||||||||
| NPI: | 1730717729 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARWICK | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22978 EL TORO RD | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926304961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493171010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 131 W MIDWAY DR | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928056507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145177107 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2020 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 131114 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.