Healthcare Provider Details

I. General information

NPI: 1942578588
Provider Name (Legal Business Name): BRIDGET ALISE WISELEY M.S., ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2011
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 ROLLING CREEK RD
SWARTHMORE PA
19081-2633
US

IV. Provider business mailing address

308 ROLLING CREEK RD
SWARTHMORE PA
19081-2633
US

V. Phone/Fax

Practice location:
  • Phone: 610-543-7766
  • Fax:
Mailing address:
  • Phone: 610-543-7766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT004234
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberJ30000402
License Number StateDE

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier22
Identifier TypeOTHER
Identifier StateDE
Identifier IssuerRESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: