Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | WI |
NPI | 1003432717 |
---|---|
Provider Name | Kyle Egerdal |
First Address | Brown Deer, WI 53209-1220 |
Second Address | Brown Deer, WI 53209-1220 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2020 |
Last Update Date | 18/06/2020 |