Provider Demographics
NPI:1023029972
Name:WEISE, DEBRA JEAN (PT)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:JEAN
Last Name:WEISE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18475 JAMAICA PATH
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-9621
Mailing Address - Country:US
Mailing Address - Phone:952-892-0440
Mailing Address - Fax:
Practice Address - Street 1:675 E NICOLLET BLVD
Practice Address - Street 2:#135
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6700
Practice Address - Country:US
Practice Address - Phone:952-892-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist