Provider Demographics
NPI:1982964979
Name:SCHMIDT, KYLE R (LAT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:R
Last Name:SCHMIDT
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 WEBB ST
Mailing Address - Street 2:APT 2
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829-8506
Mailing Address - Country:US
Mailing Address - Phone:610-470-6082
Mailing Address - Fax:
Practice Address - Street 1:1110 7TH AVE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829-9138
Practice Address - Country:US
Practice Address - Phone:715-822-6167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1263-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer