Provider Demographics
NPI:1730840141
Name:KUTSUP, KYLE DIEDRICH (ATC, LAT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:DIEDRICH
Last Name:KUTSUP
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 CONESTOGA TRL
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-2507
Mailing Address - Country:US
Mailing Address - Phone:973-460-7708
Mailing Address - Fax:
Practice Address - Street 1:35 CONESTOGA TRL
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-2507
Practice Address - Country:US
Practice Address - Phone:973-460-7708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001844002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer