Healthcare Provider Details

I. General information

NPI: 1790216869
Provider Name (Legal Business Name): KYLIE STEVENS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 E 75TH ST STE 206
INDIANAPOLIS IN
46250-2700
US

IV. Provider business mailing address

15046 HORSESHOE DR
CARMEL IN
46033-9073
US

V. Phone/Fax

Practice location:
  • Phone: 317-284-1166
  • Fax: 317-284-1559
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06005102A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: