Provider Demographics
NPI:1114707312
Name:KOWALCZYK, KYLE DAVID (DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DAVID
Last Name:KOWALCZYK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 W MAIN ST STE 120
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1548
Mailing Address - Country:US
Mailing Address - Phone:248-347-1168
Mailing Address - Fax:248-347-1252
Practice Address - Street 1:133 W MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1548
Practice Address - Country:US
Practice Address - Phone:248-347-1168
Practice Address - Fax:248-347-1252
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501302651225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist