Provider Demographics
NPI:1538743299
Name:SMITH, KYLE AUSTIN
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:AUSTIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1652 KNOLLWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-3433
Mailing Address - Country:US
Mailing Address - Phone:321-213-5291
Mailing Address - Fax:
Practice Address - Street 1:470 MALABAR RD SE UNIT 102
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-3124
Practice Address - Country:US
Practice Address - Phone:321-802-9645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT34895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist