Provider Demographics
NPI:1417997628
Name:WEITEKAMP, COLLEEN B (PT)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:B
Last Name:WEITEKAMP
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:COLLEEN
Other - Middle Name:B
Other - Last Name:MCPIKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:33 CHURCH HILL RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-1637
Practice Address - Country:US
Practice Address - Phone:475-828-0932
Practice Address - Fax:475-209-8054
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0066092251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021239-1Medicaid
CT650001196Medicare ID - Type Unspecified