Provider Demographics
NPI:1568046100
Name:WIECH, JUSTIN RYAN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:RYAN
Last Name:WIECH
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7414 SUNSET LN
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-8924
Mailing Address - Country:US
Mailing Address - Phone:502-689-9996
Mailing Address - Fax:
Practice Address - Street 1:3509 S HURSTBOURNE PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1364
Practice Address - Country:US
Practice Address - Phone:502-537-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP2021018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist