Provider Demographics
NPI:1497424915
Name:REARDON, KYLIE DONNA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:DONNA
Last Name:REARDON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-2038
Mailing Address - Country:US
Mailing Address - Phone:929-295-6566
Mailing Address - Fax:929-295-6570
Practice Address - Street 1:219 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-2038
Practice Address - Country:US
Practice Address - Phone:929-295-6566
Practice Address - Fax:929-295-6570
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT030352225100000X
NY047634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist