Provider Demographics
NPI:1972750594
Name:KREISSLER, PHILLIP WADE (DPT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WADE
Last Name:KREISSLER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 12TH AVE S
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4602
Mailing Address - Country:US
Mailing Address - Phone:208-467-4357
Mailing Address - Fax:208-467-4395
Practice Address - Street 1:1015 12TH AVE S
Practice Address - Street 2:SUITE 105
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4602
Practice Address - Country:US
Practice Address - Phone:208-467-4357
Practice Address - Fax:208-467-4395
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist