Provider Demographics
NPI:1104826957
Name:PERESIC, WANDA (PT)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:PERESIC
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:
Other - Last Name:GATTSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1150 N 75TH PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66112-3302
Mailing Address - Country:US
Mailing Address - Phone:913-299-7848
Mailing Address - Fax:913-299-7849
Practice Address - Street 1:1150 N 75TH PL
Practice Address - Street 2:SUITE 100
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-3302
Practice Address - Country:US
Practice Address - Phone:913-299-7848
Practice Address - Fax:913-299-7849
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02927225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS28805025OtherBLUECROSS BLUESHIELD
KS28805025OtherBLUECROSS BLUESHIELD