Provider Demographics
NPI:1801325956
Name:GLISCZINSKI, KRISTIN E (DPT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:E
Last Name:GLISCZINSKI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 DIAMOND DR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-6247
Mailing Address - Country:US
Mailing Address - Phone:307-258-9426
Mailing Address - Fax:
Practice Address - Street 1:1541 DIAMOND DR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-6247
Practice Address - Country:US
Practice Address - Phone:307-258-9426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-11
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-1712208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1558553339Medicaid
WY1245437599Medicaid