Provider Demographics
NPI:1972637858
Name:EBERSOLE, KYLE T (PHD, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:T
Last Name:EBERSOLE
Suffix:
Gender:M
Credentials:PHD, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 VALE ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-3592
Mailing Address - Country:US
Mailing Address - Phone:217-417-0653
Mailing Address - Fax:
Practice Address - Street 1:DEPT OF KINES & COM HLTH, FREER HALL 209, MC-052
Practice Address - Street 2:UNIVERSITY OF ILLINOIS
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-333-9517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer