Provider Demographics
NPI:1326714809
Name:DYBUL, TAYLOR (PT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:DYBUL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 GENEVA PKWY N STE A
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-4594
Mailing Address - Country:US
Mailing Address - Phone:262-249-3500
Mailing Address - Fax:
Practice Address - Street 1:700 GENEVA PKWY N STE A
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4594
Practice Address - Country:US
Practice Address - Phone:262-249-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist