Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT-985 | ID |
NPI | 1003277518 |
---|---|
Provider Name | Rebecca Wensel |
First Address | Boise, ID 83702-1132 |
Second Address | Boise, ID 83712-6241 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/03/2016 |
Last Update Date | 10/03/2016 |