Provider Demographics
NPI:1154062297
Name:WIESELER, KELSIE (PTA)
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:
Last Name:WIESELER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KELSIE
Other - Middle Name:
Other - Last Name:HIGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:56409 HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:HARTINGTON
Mailing Address - State:NE
Mailing Address - Zip Code:68739-6069
Mailing Address - Country:US
Mailing Address - Phone:402-841-6388
Mailing Address - Fax:
Practice Address - Street 1:401 W DARLENE ST
Practice Address - Street 2:
Practice Address - City:HARTINGTON
Practice Address - State:NE
Practice Address - Zip Code:68739-4510
Practice Address - Country:US
Practice Address - Phone:402-254-3905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1977225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant