Healthcare Provider Details

I. General information

NPI: 1972995454
Provider Name (Legal Business Name): KYLE DAVID HERRICK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2282 HAMBURG TPKE STE A
WAYNE NJ
07470-6291
US

IV. Provider business mailing address

2282 HAMBURG TPKE STE A
WAYNE NJ
07470-6291
US

V. Phone/Fax

Practice location:
  • Phone: 201-320-4737
  • Fax: 862-330-3186
Mailing address:
  • Phone: 973-800-4050
  • Fax: 862-330-3186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number40QA01562000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number40QA01562000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: