Provider Demographics
NPI:1295469500
Name:WADSWORTH, KIERSTAN MARIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KIERSTAN
Middle Name:MARIE
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KIERSTAN
Other - Middle Name:MARIE
Other - Last Name:KERSTETTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2222 E PHILADELPHIA ST APT 6303
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-1748
Mailing Address - Country:US
Mailing Address - Phone:570-367-0678
Mailing Address - Fax:
Practice Address - Street 1:353 FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:605-755-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist