Provider Demographics
NPI:1629230420
Name:WEISS, KERRY L (MA, PT)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:L
Last Name:WEISS
Suffix:
Gender:F
Credentials:MA, PT
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:L
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2929 SW CORNELL AVE
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-2955
Mailing Address - Country:US
Mailing Address - Phone:772-600-7615
Mailing Address - Fax:
Practice Address - Street 1:2929 SW CORNELL AVE
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-2955
Practice Address - Country:US
Practice Address - Phone:772-600-7615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5528225100000X
WI10720-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist