Provider Demographics
NPI:1881059368
Name:GIESE, KATHLEEN (LMT, BCTMB)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:GIESE
Suffix:
Gender:F
Credentials:LMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E19410 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:WATERSMEET
Mailing Address - State:MI
Mailing Address - Zip Code:49969-9718
Mailing Address - Country:US
Mailing Address - Phone:920-948-8836
Mailing Address - Fax:
Practice Address - Street 1:E19410 MILLER RD
Practice Address - Street 2:
Practice Address - City:WATERSMEET
Practice Address - State:MI
Practice Address - Zip Code:49969-9718
Practice Address - Country:US
Practice Address - Phone:920-948-8836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-28
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4377-146225700000X
MI7501014193225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7501014193OtherAUTO OWNERS INSURANCE
MI7501014193OtherPROGRESSIVE GROUP OF INSURANCE COMPANIES
MI7501014193OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI7501014193Medicaid