Provider Demographics
NPI:1184862013
Name:WEAVER, LUCINDA I (MPT)
Entity Type:Individual
Prefix:MS
First Name:LUCINDA
Middle Name:
Last Name:WEAVER
Suffix:I
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1441
Mailing Address - Street 2:
Mailing Address - City:GUALALA
Mailing Address - State:CA
Mailing Address - Zip Code:95445-1441
Mailing Address - Country:US
Mailing Address - Phone:707-884-4800
Mailing Address - Fax:707-884-4808
Practice Address - Street 1:39120 OCEAN DR.
Practice Address - Street 2:
Practice Address - City:GUALALA
Practice Address - State:CA
Practice Address - Zip Code:95445
Practice Address - Country:US
Practice Address - Phone:707-884-4800
Practice Address - Fax:707-884-4808
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014743-12251S0007X, 2251X0800X
CAPT205412251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports