Provider Demographics
NPI:1326570201
Name:HAAKE, KYLE ALLEN (PT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ALLEN
Last Name:HAAKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-9109
Mailing Address - Fax:515-643-9138
Practice Address - Street 1:307 E SCENIC VALLEY AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125-4865
Practice Address - Country:US
Practice Address - Phone:515-643-9109
Practice Address - Fax:515-643-9138
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA086035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist