Provider Demographics
NPI:1164132551
Name:PETERSON, KYLA RENEE (PT, DPT, OCS)
Entity Type:Individual
Prefix:DR
First Name:KYLA
Middle Name:RENEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 HOMESTEAD EST
Mailing Address - Street 2:
Mailing Address - City:CLANCY
Mailing Address - State:MT
Mailing Address - Zip Code:59634-9661
Mailing Address - Country:US
Mailing Address - Phone:406-546-4578
Mailing Address - Fax:406-502-1783
Practice Address - Street 1:3150 N MONTANA AVE STE D
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-7804
Practice Address - Country:US
Practice Address - Phone:406-546-4578
Practice Address - Fax:406-502-1783
Is Sole Proprietor?:No
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-4350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist