Provider Demographics
NPI:1235835232
Name:DITZENBERGER, KYLE (DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:DITZENBERGER
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 1:576 INDUSTRIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-4413
Mailing Address - Country:US
Mailing Address - Phone:330-577-3640
Mailing Address - Fax:
Practice Address - Street 1:576 INDUSTRIAL PKWY
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44022-4413
Practice Address - Country:US
Practice Address - Phone:330-577-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT020118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist