Provider Demographics
NPI:1366694788
Name:WEBER, KYLE P (PT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:P
Last Name:WEBER
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 1:13445 TOSCA CT
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-1343
Mailing Address - Country:US
Mailing Address - Phone:612-220-5361
Mailing Address - Fax:
Practice Address - Street 1:13445 TOSCA CT
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-1343
Practice Address - Country:US
Practice Address - Phone:612-220-5361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12288-242251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619980OtherBCBS OF IL