Provider Demographics
NPI:1386029528
Name:WISEHART, KENDALL (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:WISEHART
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 EASTLAKE AVE E STE 110
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-7125
Mailing Address - Country:US
Mailing Address - Phone:206-405-1864
Mailing Address - Fax:
Practice Address - Street 1:3221 EASTLAKE AVE E STE 110
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-7125
Practice Address - Country:US
Practice Address - Phone:206-405-1864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60591574225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist