Provider Demographics
NPI:1730812504
Name:PHAM, KYLER NGUYEN
Entity type:Individual
Prefix:
First Name:KYLER
Middle Name:NGUYEN
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 BENNINGTON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-4879
Mailing Address - Country:US
Mailing Address - Phone:480-399-7072
Mailing Address - Fax:
Practice Address - Street 1:154 BENNINGTON ST APT 2
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-4879
Practice Address - Country:US
Practice Address - Phone:480-399-7072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1861568107OtherOTHER