Provider Demographics
NPI:1528036878
Name:WIESE, KORRYN (PT, CMPT)
Entity Type:Individual
Prefix:
First Name:KORRYN
Middle Name:
Last Name:WIESE
Suffix:
Gender:F
Credentials:PT, CMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5856 HARRISON BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4397
Mailing Address - Country:US
Mailing Address - Phone:801-475-6415
Mailing Address - Fax:801-475-6417
Practice Address - Street 1:5856 HARRISON BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4397
Practice Address - Country:US
Practice Address - Phone:801-475-6415
Practice Address - Fax:801-475-6417
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2007-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT117905-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT00058187Medicare ID - Type UnspecifiedSUB CHAPTER S CORP