Provider Demographics
NPI:1710311261
Name:WEITZ, BRIAN E (PTA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:E
Last Name:WEITZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 S. RAPIDS RD.
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220
Mailing Address - Country:US
Mailing Address - Phone:920-684-1144
Mailing Address - Fax:
Practice Address - Street 1:960 S. RAPIDS RD.
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220
Practice Address - Country:US
Practice Address - Phone:920-684-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-01
Last Update Date:2013-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2089-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant