Healthcare Provider Details

I. General information

NPI: 1710533625
Provider Name (Legal Business Name): KYLE DELIBERTY DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 01/15/2024
Certification Date: 01/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 STILLWATER AVE STE 5
OLD TOWN ME
04468-2215
US

IV. Provider business mailing address

601 STILLWATER AVE STE 5
OLD TOWN ME
04468-2215
US

V. Phone/Fax

Practice location:
  • Phone: 207-817-0214
  • Fax:
Mailing address:
  • Phone: 207-404-3530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6173
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: