Provider Demographics
NPI:1215785282
Name:WEISS, KYLA RAE (PT, DPT)
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:RAE
Last Name:WEISS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KYLA
Other - Middle Name:RAE
Other - Last Name:GOGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:841 S CAROL DR W
Mailing Address - Street 2:
Mailing Address - City:SANTA CLAUS
Mailing Address - State:IN
Mailing Address - Zip Code:47579-6118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LOOGOOTEE
Practice Address - State:IN
Practice Address - Zip Code:47553-1708
Practice Address - Country:US
Practice Address - Phone:812-709-3286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012557A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation