Provider Demographics
NPI:1114611464
Name:WEISSMULLER, BRIAN JAY (ATC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAY
Last Name:WEISSMULLER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1371 CAMPBELL CT
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-2211
Mailing Address - Country:US
Mailing Address - Phone:973-903-7089
Mailing Address - Fax:
Practice Address - Street 1:1371 CAMPBELL CT
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-2211
Practice Address - Country:US
Practice Address - Phone:973-903-7089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL57092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer