Provider Demographics
NPI:1720434467
Name:DODGE, KYLE (DPT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:DODGE
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 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1940
Mailing Address - Fax:
Practice Address - Street 1:19843 WOLF RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-1315
Practice Address - Country:US
Practice Address - Phone:708-479-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022331225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist