Provider Demographics
NPI:1417653742
Name:COSTANTINI, KYLE (ATC, LAT, MAT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:COSTANTINI
Suffix:
Gender:M
Credentials:ATC, LAT, MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 UPTOWN AVE APT B3013
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-4795
Mailing Address - Country:US
Mailing Address - Phone:321-332-2972
Mailing Address - Fax:
Practice Address - Street 1:2199 S UNIV BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-4711
Practice Address - Country:US
Practice Address - Phone:321-332-2972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00023902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer