Provider Demographics
NPI:1487696795
Name:KYLE, MARJORIE TERESA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:TERESA
Last Name:KYLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MARJORIE
Other - Middle Name:TERESA
Other - Last Name:KYLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:3705 ARCTIC BLVD # 406
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-5774
Mailing Address - Country:US
Mailing Address - Phone:607-230-2190
Mailing Address - Fax:
Practice Address - Street 1:4982 ZUKERT AVE
Practice Address - Street 2:RM 126
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99505
Practice Address - Country:US
Practice Address - Phone:907-580-0715
Practice Address - Fax:907-580-0629
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31369103TC2200X
AK628103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1724726Medicaid
AK628OtherBOARD OF PSYCHOLOGIST