Provider Demographics
NPI:1255855045
Name:WEILAND, HOLLY J (DPT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:J
Last Name:WEILAND
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:HATCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:210 WISCONSIN AMERICAN DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-2999
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 WISCONSIN AMERICAN DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-2999
Practice Address - Country:US
Practice Address - Phone:920-907-7270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13512-24208100000X
WI13512225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10070734Medicaid