Provider Demographics
NPI:1598730244
Name:KISSEL, JIM F (PT ATC)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:F
Last Name:KISSEL
Suffix:
Gender:M
Credentials:PT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 HARPER RD
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-9133
Mailing Address - Country:US
Mailing Address - Phone:419-782-8836
Mailing Address - Fax:
Practice Address - Street 1:851 S CLINTON ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2770
Practice Address - Country:US
Practice Address - Phone:419-782-8808
Practice Address - Fax:419-782-8148
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT7200225100000X
OHAT0020342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2343075Medicaid
OH4059093Medicare ID - Type Unspecified