Basic Information
| Provider Information | |||||||||
| NPI: | 1598023301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIRSIG | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORELOCK | ||||||||
| OtherFirstName: | BETHANY | ||||||||
| OtherMiddleName: | DALE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17134 BEL RAY PL | ||||||||
| Address2: | |||||||||
| City: | BELTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640125331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162264011 | ||||||||
| FaxNumber: | 8165246115 | ||||||||
| Practice Location | |||||||||
| Address1: | 3747 SW RAINTREE DR | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640824606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165375650 | ||||||||
| FaxNumber: | 8165375649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2012 | ||||||||
| LastUpdateDate: | 02/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2012023674 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 47471021 | 01 | BCBS KC | OTHER | MA4370034 | 01 | MO | MEDICARE PTAN | OTHER |