Provider Demographics
NPI:1730908542
Name:WESSENBERG, STEPHEN ALFRED (PTA, BS, AS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ALFRED
Last Name:WESSENBERG
Suffix:
Gender:M
Credentials:PTA, BS, AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4709 SHELL BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-5641
Mailing Address - Country:US
Mailing Address - Phone:307-274-6717
Mailing Address - Fax:
Practice Address - Street 1:10004 204TH AVE E STE 3100
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6540
Practice Address - Country:US
Practice Address - Phone:253-987-7509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPTA-1143225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant