Provider Demographics
NPI:1376341594
Name:WIELAND, BLAINE JOSEPH (PT)
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:JOSEPH
Last Name:WIELAND
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 STRASSNER DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1872
Mailing Address - Country:US
Mailing Address - Phone:423-946-0934
Mailing Address - Fax:
Practice Address - Street 1:1335 STRASSNER DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-1872
Practice Address - Country:US
Practice Address - Phone:423-946-0934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1145530225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist