Provider Demographics
NPI:1861759631
Name:CORBETT, KYLE OMAR (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:OMAR
Last Name:CORBETT
Suffix:
Gender:M
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:PO BOX 8000
Mailing Address - Street 2:
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-8000
Mailing Address - Country:US
Mailing Address - Phone:516-686-3734
Mailing Address - Fax:516-686-7890
Practice Address - Street 1:NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:OLD WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11568-3532
Practice Address - Country:US
Practice Address - Phone:516-686-3734
Practice Address - Fax:516-686-7890
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033397-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1861759631Medicaid