Provider Demographics
NPI:1295420859
Name:FITZSTEVENS, KYLE (OTD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FITZSTEVENS
Suffix:
Gender:M
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 J ST STE 210
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-4734
Mailing Address - Country:US
Mailing Address - Phone:916-444-0033
Mailing Address - Fax:
Practice Address - Street 1:8376 FRUITRIDGE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95828-0949
Practice Address - Country:US
Practice Address - Phone:916-422-0571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA463011225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics