Provider Demographics
NPI:1932661352
Name:DIETRICH, KYLE PHILLIP (LMT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:PHILLIP
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 SAINTS LOOP APT B
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59602-7657
Mailing Address - Country:US
Mailing Address - Phone:626-818-2780
Mailing Address - Fax:
Practice Address - Street 1:1203 MOUNT AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5601
Practice Address - Country:US
Practice Address - Phone:626-818-2780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-15881225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty