Healthcare Provider Details

I. General information

NPI: 1265682538
Provider Name (Legal Business Name): MARY ELIZABETH KYLE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 01/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25250 75TH ST
SALEM WI
53168-8705
US

IV. Provider business mailing address

5846 N RIVER BAY RD
WATERFORD WI
53185-3033
US

V. Phone/Fax

Practice location:
  • Phone: 262-843-4200
  • Fax:
Mailing address:
  • Phone: 309-368-5280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11118-024
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070015014
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: