Provider Demographics
NPI:1083432108
Name:PRISICHENKO, KYRYL (DPT)
Entity type:Individual
Prefix:
First Name:KYRYL
Middle Name:
Last Name:PRISICHENKO
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 1:3369 QUIGGLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9291
Mailing Address - Country:US
Mailing Address - Phone:616-558-6701
Mailing Address - Fax:
Practice Address - Street 1:2550 N HOLLYWOOD WAY STE 100
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-5015
Practice Address - Country:US
Practice Address - Phone:818-524-3730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty