Provider Demographics
NPI:1124306220
Name:WISTED, CYNTHIA KAY (DPT)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:KAY
Last Name:WISTED
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 1:4 RICHMOND SQ STE 200
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5117
Mailing Address - Country:US
Mailing Address - Phone:401-433-4172
Mailing Address - Fax:401-433-0612
Practice Address - Street 1:21 DIVISION ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-5352
Practice Address - Country:US
Practice Address - Phone:017-267-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8764225100000X
MA24042225100000X
RIPT03378225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN650002709Medicare PIN