Provider Demographics
NPI:1588112049
Name:CALIVA, DYLAN SAMUAL (DPT, PT)
Entity type:Individual
Prefix:MR
First Name:DYLAN
Middle Name:SAMUAL
Last Name:CALIVA
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 EDWARD ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-2220
Mailing Address - Country:US
Mailing Address - Phone:262-716-7494
Mailing Address - Fax:
Practice Address - Street 1:2755 SILVER CREEK RD
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7904
Practice Address - Country:US
Practice Address - Phone:928-704-2194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist