=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972315935
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DUSTYN WIELAND
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2025
-----------------------------------------------------
Last Update Date | 01/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17250 BROOKSIDE CT
-----------------------------------------------------
City | TOWNSEND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54175-9622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-276-6650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17745 HOLIDAY ACRES LN
-----------------------------------------------------
City | TOWNSEND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54175-9579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-279-9768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 17229-146
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------