Provider Demographics
NPI:1972315935
Name:WIELAND, DUSTYN
Entity type:Individual
Prefix:
First Name:DUSTYN
Middle Name:
Last Name:WIELAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17745 HOLIDAY ACRES LN
Mailing Address - Street 2:
Mailing Address - City:TOWNSEND
Mailing Address - State:WI
Mailing Address - Zip Code:54175-9579
Mailing Address - Country:US
Mailing Address - Phone:920-279-9768
Mailing Address - Fax:
Practice Address - Street 1:17250 BROOKSIDE CT
Practice Address - Street 2:
Practice Address - City:TOWNSEND
Practice Address - State:WI
Practice Address - Zip Code:54175-9622
Practice Address - Country:US
Practice Address - Phone:715-276-6650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17229-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty