Provider Demographics
NPI:1720484371
Name:WIENS, TERYN (PT, DPT)
Entity type:Individual
Prefix:
First Name:TERYN
Middle Name:
Last Name:WIENS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:TERYN
Other - Middle Name:
Other - Last Name:KALDHEIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:805 SW INDUSTRIAL WAY STE 3
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1093
Mailing Address - Country:US
Mailing Address - Phone:541-416-7476
Mailing Address - Fax:
Practice Address - Street 1:1590 NE 3RD ST STE B
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-2916
Practice Address - Country:US
Practice Address - Phone:541-416-7476
Practice Address - Fax:541-416-7478
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60781225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500679012Medicaid
ORR178680Medicare PIN