Provider Demographics
NPI:1417562984
Name:WEBER, MICAELA R
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:R
Last Name:WEBER
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 1:561 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-2433
Mailing Address - Country:US
Mailing Address - Phone:570-244-5567
Mailing Address - Fax:
Practice Address - Street 1:15900 ROUTE 6
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:PA
Practice Address - Zip Code:16947-9308
Practice Address - Country:US
Practice Address - Phone:570-297-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP009790224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant