Healthcare Provider Details

I. General information

NPI: 1205429636
Provider Name (Legal Business Name): KYLE GLICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 02/17/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 RECREATION BUILDING
UNIVERSITY PARK PA
16802-5700
US

IV. Provider business mailing address

357 HUDSON DR
BRICK NJ
08723-5920
US

V. Phone/Fax

Practice location:
  • Phone: 814-865-5284
  • Fax:
Mailing address:
  • Phone: 732-948-1328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

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: