Provider Demographics
NPI:1346493889
Name:WEISMAN, STACY DELAYNE
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:DELAYNE
Last Name:WEISMAN
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 1:706 WOODLAWN DR
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-9398
Mailing Address - Country:US
Mailing Address - Phone:812-634-2617
Mailing Address - Fax:812-482-2193
Practice Address - Street 1:706 WOODLAWN DR
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-9398
Practice Address - Country:US
Practice Address - Phone:812-634-2617
Practice Address - Fax:812-482-2193
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200636320222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist