Healthcare Provider Details

I. General information

NPI: 1972974822
Provider Name (Legal Business Name): KYLIE N WATTS PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KYLIE M NOVIA DPT

II. Dates (important events)

Enumeration Date: 10/16/2015
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DOCTORS DR
GREENVILLE SC
29605-4265
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 864-797-7320
  • Fax: 864-797-7325
Mailing address:
  • Phone: 630-296-2223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1264811
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8076
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: