Basic Information
| Provider Information | |||||||||
| NPI: | 1265682538 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KYLE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5846 N RIVER BAY RD | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531853033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093685280 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25250 75TH ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531688705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628434200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2008 | ||||||||
| LastUpdateDate: | 01/28/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11118-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 070015014 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.