Healthcare Provider Details

I. General information

NPI: 1841473527
Provider Name (Legal Business Name): KRISTEN S. WIESE MA, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 04/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 BLEDSOE RD NW
LOS RANCHOS NM
87107-6219
US

IV. Provider business mailing address

1104 SALAMANCA ST NW
ALBUQUERQUE NM
87107-5626
US

V. Phone/Fax

Practice location:
  • Phone: 505-908-0717
  • Fax:
Mailing address:
  • Phone: 505-908-0717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2414
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225XH1300X
TaxonomyHuman Factors Occupational Therapist
License Number2414
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number2414
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2414
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: