Provider Demographics
NPI:1083366769
Name:WEINBERG, KELSEY LYNNE WIIG (MA61244752)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNNE WIIG
Last Name:WEINBERG
Suffix:
Gender:F
Credentials:MA61244752
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 MAIN ST STE 14C
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9472
Mailing Address - Country:US
Mailing Address - Phone:360-366-8398
Mailing Address - Fax:
Practice Address - Street 1:1920 MAIN ST STE 14C
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-9472
Practice Address - Country:US
Practice Address - Phone:360-366-8398
Practice Address - Fax:360-922-6101
Is Sole Proprietor?:No
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61244752225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist