Provider Demographics
NPI:1952006926
Name:BIRELY, KYLE JACOB (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JACOB
Last Name:BIRELY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2806 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2870
Mailing Address - Country:US
Mailing Address - Phone:309-655-6961
Mailing Address - Fax:
Practice Address - Street 1:2806 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-2870
Practice Address - Country:US
Practice Address - Phone:309-655-6961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP22028225100000X
IL070.027313225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist