Provider Demographics
NPI:1720465149
Name:WEHRLE, BAILEY L (AT)
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:L
Last Name:WEHRLE
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:BAILEY
Other - Middle Name:L
Other - Last Name:LICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:E2638 MARION LN
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-8424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N2930 STATE ROAD 22
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-5267
Practice Address - Country:US
Practice Address - Phone:920-361-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIL200-0729-3909-082255A2300X
WI18642255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer