Provider Demographics
NPI:1922108166
Name:DETTWILER, KIRSTEN L (PT)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:L
Last Name:DETTWILER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 WEST AVENUE S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4783
Mailing Address - Country:US
Mailing Address - Phone:608-392-9768
Mailing Address - Fax:608-392-7124
Practice Address - Street 1:700 WEST AVENUE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4783
Practice Address - Country:US
Practice Address - Phone:608-392-9768
Practice Address - Fax:608-392-7124
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03705225100000X
WI10009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist