Provider Demographics
NPI:1083831838
Name:WEAVER, MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:HARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1887 N STATE HIGHWAY CC
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-8015
Mailing Address - Country:US
Mailing Address - Phone:417-725-5774
Mailing Address - Fax:417-725-5915
Practice Address - Street 1:1887 N STATE HIGHWAY CC
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-8015
Practice Address - Country:US
Practice Address - Phone:417-725-5774
Practice Address - Fax:417-725-5915
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002022558225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant