Provider Demographics
NPI:1235263146
Name:MEDLIN, DEBORA KIESSEL (PT)
Entity Type:Individual
Prefix:
First Name:DEBORA
Middle Name:KIESSEL
Last Name:MEDLIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 THAYER CTR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-1116
Mailing Address - Country:US
Mailing Address - Phone:301-334-1863
Mailing Address - Fax:301-334-5835
Practice Address - Street 1:6500 THAYER CTR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1116
Practice Address - Country:US
Practice Address - Phone:301-334-1863
Practice Address - Fax:301-334-5835
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19741225100000X
WV002043225100000X
PAPT016587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD186300200Medicaid
MD186300200Medicaid