Healthcare Provider Details

I. General information

NPI: 1225888720
Provider Name (Legal Business Name): KYLAN SEVILLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 MADISON ST
MANCHESTER CT
06040-5333
US

IV. Provider business mailing address

19 MADISON ST
MANCHESTER CT
06040-5333
US

V. Phone/Fax

Practice location:
  • Phone: 347-217-0460
  • Fax:
Mailing address:
  • Phone: 347-217-0460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: