Provider Demographics
NPI:1629587340
Name:WEISBECKER, GRACE ANNE (ATC)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ANNE
Last Name:WEISBECKER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WOODS RD
Mailing Address - Street 2:
Mailing Address - City:TIVOLI
Mailing Address - State:NY
Mailing Address - Zip Code:12583-5429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 WOODS RD
Practice Address - Street 2:
Practice Address - City:TIVOLI
Practice Address - State:NY
Practice Address - Zip Code:12583-5429
Practice Address - Country:US
Practice Address - Phone:845-798-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003450-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer