Provider Demographics
NPI:1801387535
Name:CLEVENGER, KYLE DEAN (DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DEAN
Last Name:CLEVENGER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7825 3RD ST N STE 105
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5444
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:888-425-0398
Practice Address - Street 1:2665 W 78TH ST
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-4502
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:888-425-0398
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN11149225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist