Basic Information
Provider Information | |||||||||
NPI: | 1649428012 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KREUSEL | ||||||||
FirstName: | DANA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BUGAS | ||||||||
OtherFirstName: | DANA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 520 WILKES DR STE 17 | ||||||||
Address2: |   | ||||||||
City: | GREEN RIVER | ||||||||
State: | WY | ||||||||
PostalCode: | 829354854 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3078751788 | ||||||||
FaxNumber: | 3078758817 | ||||||||
Practice Location | |||||||||
Address1: | 520 WILKES DR STE 17 | ||||||||
Address2: |   | ||||||||
City: | GREEN RIVER | ||||||||
State: | WY | ||||||||
PostalCode: | 82935 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3078751788 | ||||||||
FaxNumber: | 3078758811 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2008 | ||||||||
LastUpdateDate: | 02/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1532 | WY | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.