Provider Demographics
NPI:1518202332
Name:WILLETS, KYLE A (PT,DPT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:A
Last Name:WILLETS
Suffix:
Gender:F
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 1:5350 MANHATTAN CIR 100
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-4272
Mailing Address - Country:US
Mailing Address - Phone:303-543-1201
Mailing Address - Fax:303-543-1206
Practice Address - Street 1:180 WESTBROOK RD
Practice Address - Street 2:#3
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1517
Practice Address - Country:US
Practice Address - Phone:860-767-7587
Practice Address - Fax:860-767-3418
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100064903Medicare UPIN