Provider Demographics
NPI:1043764640
Name:WOODARD, KYLIE MAE (PT)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:MAE
Last Name:WOODARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 W BELMONT DR
Mailing Address - Street 2:SUITE 12
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-3064
Mailing Address - Country:US
Mailing Address - Phone:706-625-0662
Mailing Address - Fax:706-625-0582
Practice Address - Street 1:136 W BELMONT DR
Practice Address - Street 2:SUITE 12
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-3064
Practice Address - Country:US
Practice Address - Phone:706-625-0662
Practice Address - Fax:706-625-0582
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTO12523225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPTO12523OtherPT LICENSE