Provider Demographics
NPI:1942394903
Name:KIESLICH, SARAH A (PT)
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:A
Last Name:KIESLICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:A
Other - Last Name:MOULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776
Mailing Address - Street 2:184 ROUTE 7 SOUTH
Mailing Address - City:MILTON
Mailing Address - State:VT
Mailing Address - Zip Code:05468-0776
Mailing Address - Country:US
Mailing Address - Phone:802-893-7427
Mailing Address - Fax:802-893-7429
Practice Address - Street 1:184 ROUTE 7 SOUTH
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:VT
Practice Address - Zip Code:05468-0776
Practice Address - Country:US
Practice Address - Phone:802-893-7427
Practice Address - Fax:802-893-7429
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400003247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00058778OtherBLUE CROSS BLUE SHIELD
VTOVN2844Medicaid
430051OtherMVP HEALTHCARE
VT00058778OtherBLUE CROSS BLUE SHIELD