Provider Demographics
NPI:1295583516
Name:KINDER, KYLE MINOR
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:MINOR
Last Name:KINDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 DUVAL DR
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1608
Mailing Address - Country:US
Mailing Address - Phone:217-883-9315
Mailing Address - Fax:
Practice Address - Street 1:400 S STATION RD
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-2743
Practice Address - Country:US
Practice Address - Phone:618-288-5014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004580224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant