Provider Demographics
NPI:1841473527
Name:WIESE, KRISTEN S (MA, OTR/L)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:S
Last Name:WIESE
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 SALAMANCA ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5626
Mailing Address - Country:US
Mailing Address - Phone:505-908-0717
Mailing Address - Fax:
Practice Address - Street 1:608 BLEDSOE RD NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6219
Practice Address - Country:US
Practice Address - Phone:505-908-0717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2414225X00000X, 225XH1300X, 225XN1300X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHuman Factors
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics