Provider Demographics
NPI:1164469565
Name:WEYANDT, STEPHEN RUSSELL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RUSSELL
Last Name:WEYANDT
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:277 HIGHWAY 74 N
Practice Address - Street 2:SUITE 203
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1569
Practice Address - Country:US
Practice Address - Phone:678-364-0337
Practice Address - Fax:678-364-0858
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT6708225100000X
ALPTH7978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBDDZMedicare ID - Type Unspecified