Provider Demographics
NPI:1639701758
Name:DWYER, KYLE (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:DWYER
Suffix:
Gender:M
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 EDGE WOOD CT APT A
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-9632
Mailing Address - Country:US
Mailing Address - Phone:630-201-2366
Mailing Address - Fax:
Practice Address - Street 1:1600 EDGE WOOD CT APT A
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-9632
Practice Address - Country:US
Practice Address - Phone:630-201-2366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2440-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer