Provider Demographics
NPI:1245853175
Name:LARSON, KYLE ANTHONY (DPT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:ANTHONY
Last Name:LARSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54005-0147
Mailing Address - Country:US
Mailing Address - Phone:715-263-4103
Mailing Address - Fax:715-263-4110
Practice Address - Street 1:417 3RD AVENUE
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:WI
Practice Address - Zip Code:54005-8905
Practice Address - Country:US
Practice Address - Phone:715-263-4103
Practice Address - Fax:715-263-4110
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14996-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist