Provider Demographics
NPI:1477394112
Name:KIPP, DYLAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:KIPP
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 1:118 HEATH HILL RD
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-9701
Mailing Address - Country:US
Mailing Address - Phone:419-606-5127
Mailing Address - Fax:
Practice Address - Street 1:6400 HIGHWAY 9
Practice Address - Street 2:STE D
Practice Address - City:INMAN
Practice Address - State:SC
Practice Address - Zip Code:29349-6927
Practice Address - Country:US
Practice Address - Phone:864-699-9441
Practice Address - Fax:864-699-9279
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist