Provider Demographics
NPI:1528200599
Name:WEIDNER, HEIDI ELIZABETH BARES (PT)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:ELIZABETH BARES
Last Name:WEIDNER
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 1:6650 W STATE ST
Mailing Address - Street 2:UNIT D 136
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5150 N PORT WASHINGTON RD
Practice Address - Street 2:#130
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5474
Practice Address - Country:US
Practice Address - Phone:414-418-6578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10420-024225100000X
FLPT 24498225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist