Healthcare Provider Details

I. General information

NPI: 1366694788
Provider Name (Legal Business Name): KYLE P WEBER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13445 TOSCA CT
ELM GROVE WI
53122-1343
US

IV. Provider business mailing address

13445 TOSCA CT
ELM GROVE WI
53122-1343
US

V. Phone/Fax

Practice location:
  • Phone: 612-220-5361
  • Fax:
Mailing address:
  • Phone: 612-220-5361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12288
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number12288-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: