Provider Demographics
NPI:1336123314
Name:KIESEL, KYLE B (MPT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:B
Last Name:KIESEL
Suffix:
Gender:M
Credentials:MPT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 E INDIANA ST
Mailing Address - Street 2:STE. 102
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2794
Mailing Address - Country:US
Mailing Address - Phone:812-476-0409
Mailing Address - Fax:812-476-1016
Practice Address - Street 1:7300 E INDIANA ST
Practice Address - Street 2:STE. 102
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2794
Practice Address - Country:US
Practice Address - Phone:812-476-0409
Practice Address - Fax:812-476-1016
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006922A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200839530Medicaid
IN000000199654OtherBLUE CROSS BLUE SHIELD
IN200839530Medicaid