Provider Demographics
NPI:1336690080
Name:WEAVER, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7331 GLENBURN DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4087
Mailing Address - Country:US
Mailing Address - Phone:316-644-0371
Mailing Address - Fax:
Practice Address - Street 1:5623 PULPIT PEAK VW
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3954
Practice Address - Country:US
Practice Address - Phone:316-644-3071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COAT.00022532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program