Provider Demographics
NPI:1790904191
Name:WEAVER, DARLA JOAN (PT)
Entity Type:Individual
Prefix:MRS
First Name:DARLA
Middle Name:JOAN
Last Name:WEAVER
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 1:227 DUBBS WAY
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72927-7849
Mailing Address - Country:US
Mailing Address - Phone:479-675-2898
Mailing Address - Fax:
Practice Address - Street 1:1414 S ELM ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:AR
Practice Address - Zip Code:72855-4924
Practice Address - Country:US
Practice Address - Phone:479-963-6151
Practice Address - Fax:479-963-3331
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT14472251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128029721Medicaid