Provider Demographics
NPI:1598023301
Name:WIRSIG, BETHANY DALE (DPT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:DALE
Last Name:WIRSIG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:DALE
Other - Last Name:MORELOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17134 BEL RAY PL
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-5331
Mailing Address - Country:US
Mailing Address - Phone:816-226-4011
Mailing Address - Fax:816-524-6115
Practice Address - Street 1:3747 SW RAINTREE DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64082-4606
Practice Address - Country:US
Practice Address - Phone:816-537-5650
Practice Address - Fax:816-537-5649
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012023674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
47471021OtherBCBS KC
MOMA4370034OtherMEDICARE PTAN
MOK86000019Medicare PIN