Healthcare Provider Details

I. General information

NPI: 1154875581
Provider Name (Legal Business Name): MEGAN L WIEDLER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN L KUSCHKE DPT

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 DENSLOW RD
EAST LONGMEADOW MA
01028-3188
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 413-526-9924
  • Fax: 413-529-9961
Mailing address:
  • Phone: 630-296-2223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number22502
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: