Provider Demographics
NPI:1164874715
Name:BLEVINGS, KYLE MATTHEW (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:MATTHEW
Last Name:BLEVINGS
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 GLENMORE AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-2258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3012 GLENMORE AVE STE 104
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-2258
Practice Address - Country:US
Practice Address - Phone:844-584-7284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000150732255A2300X
TNAT 00000017662255A2300X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000015073OtherBOARD OF CERTIFICATION (BOC)
TNAT 0000001766OtherSTATE OF TENNESSEE DIVISION OF HEALTH RELATED BOARDS