Provider Demographics
NPI:1235618471
Name:WYSONG, KINSEY SHAYE
Entity Type:Individual
Prefix:
First Name:KINSEY
Middle Name:SHAYE
Last Name:WYSONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KINSEY
Other - Middle Name:SHAYE
Other - Last Name:WYSONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:KINSEY LENGERICH
Mailing Address - Street 1:8333 GARDEN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-3927
Mailing Address - Country:US
Mailing Address - Phone:260-692-2350
Mailing Address - Fax:
Practice Address - Street 1:377 WESTRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-2137
Practice Address - Country:US
Practice Address - Phone:260-692-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006037A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist