Provider Demographics
NPI:1952045841
Name:KIESLICH, MACKENZIE NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:NICOLE
Last Name:KIESLICH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9504 N CHARLOTTE CT
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-3124
Mailing Address - Country:US
Mailing Address - Phone:816-694-9901
Mailing Address - Fax:
Practice Address - Street 1:8250 N CHURCH RD STE B
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64158-1103
Practice Address - Country:US
Practice Address - Phone:816-792-0524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020034312225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant