Provider Demographics
NPI:1790248326
Name:KIRST, KYLE (OTR)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:KIRST
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 COUNTY ROAD D
Mailing Address - Street 2:
Mailing Address - City:BELGIUM
Mailing Address - State:WI
Mailing Address - Zip Code:53004-9722
Mailing Address - Country:US
Mailing Address - Phone:262-365-4595
Mailing Address - Fax:
Practice Address - Street 1:377 W RIVER WOODS PKWY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212-1088
Practice Address - Country:US
Practice Address - Phone:414-964-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6482-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist