Provider Demographics
NPI:1710131032
Name:WEAVER, JOSHUA DAVID (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:DAVID
Last Name:WEAVER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:11112 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-5749
Practice Address - Country:US
Practice Address - Phone:253-537-1103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014153225100000X
WAPT60051171225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2006102Medicaid
MI5501014153OtherMI LICENSE
WA0329317OtherWA L&I
WA1710131032Medicaid
MI5501014153OtherMI LICENSE
WA1710131032Medicaid
WA2006102Medicaid
WAG8937175Medicare PIN