Provider Demographics
NPI:1174525653
Name:LYTHGOE, KYLE O (PSYD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:O
Last Name:LYTHGOE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 COMANCHE RD
Mailing Address - Street 2:
Mailing Address - City:FORT MEADE
Mailing Address - State:SD
Mailing Address - Zip Code:57741-1002
Mailing Address - Country:US
Mailing Address - Phone:605-347-2511
Mailing Address - Fax:
Practice Address - Street 1:113 COMANCHE RD
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:SD
Practice Address - Zip Code:57741-1002
Practice Address - Country:US
Practice Address - Phone:605-347-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE554103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE08436OtherBLUE CROSS BLUE SHIELD NE
NEP38477Medicare UPIN
NE275759Medicare ID - Type Unspecified