Provider Demographics
NPI:1063009587
Name:HEISE, KYLE MARTIN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MARTIN
Last Name:HEISE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14256 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5423
Mailing Address - Country:US
Mailing Address - Phone:313-930-0366
Mailing Address - Fax:
Practice Address - Street 1:23965 NOVI RD STE 150
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-0203
Practice Address - Country:US
Practice Address - Phone:248-513-3730
Practice Address - Fax:238-513-3733
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist