Provider Demographics
NPI:1760137483
Name:DAVIS, KYLE STONE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:STONE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KYLE
Other - Middle Name:LEE
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 SPRING ST SE STE 101
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3773
Mailing Address - Country:US
Mailing Address - Phone:770-615-7676
Mailing Address - Fax:770-615-0177
Practice Address - Street 1:500 SPRING ST SE STE 101
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3773
Practice Address - Country:US
Practice Address - Phone:770-615-7676
Practice Address - Fax:770-615-0177
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT015779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA841619876Medicaid