Provider Demographics
NPI:1457365538
Name:WESOLOWSKI, KATHLEEN JOHNSON (PT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JOHNSON
Last Name:WESOLOWSKI
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 1:1832 N BELLO SARA WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6989
Mailing Address - Country:US
Mailing Address - Phone:408-439-2414
Mailing Address - Fax:
Practice Address - Street 1:450 W STATE ST STE 270
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6974
Practice Address - Country:US
Practice Address - Phone:208-462-0808
Practice Address - Fax:208-516-4488
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-92072251X0800X
CAPT15209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-9207OtherSTATE LICENSE
CAPT15209OtherSTATE LICENSE