Provider Demographics
NPI:1326597121
Name:DIEBOLD, KAYLA (DPT)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:DIEBOLD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:
Other - Last Name:STOCKDALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:33900 HARPER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-416-9100
Mailing Address - Fax:586-416-9103
Practice Address - Street 1:5141 OAKMAN BLVD
Practice Address - Street 2:STE D
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3763
Practice Address - Country:US
Practice Address - Phone:313-359-8200
Practice Address - Fax:313-359-8201
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist