Provider Demographics
NPI:1598515132
Name:REISENBICHLER, KYLIE SUZANNE
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:SUZANNE
Last Name:REISENBICHLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 COUNTY ROAD 319
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-8078
Mailing Address - Country:US
Mailing Address - Phone:573-837-9177
Mailing Address - Fax:
Practice Address - Street 1:20794 US HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-7260
Practice Address - Country:US
Practice Address - Phone:573-471-2686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024007514224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant