Provider Demographics
NPI:1407067606
Name:WIEGAND, BETH ELLEN (PT)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ELLEN
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3616 HILLSBORO RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4471
Mailing Address - Country:US
Mailing Address - Phone:502-797-0422
Mailing Address - Fax:
Practice Address - Street 1:3616 HILLSBORO RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4471
Practice Address - Country:US
Practice Address - Phone:502-797-0422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY001071225100000X
IN05001815A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist