Provider Demographics
NPI:1811628050
Name:WIECHMANN, MEGAN (PT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:WIECHMANN
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 1:2300 DUPONT DR APT 302
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-8577
Mailing Address - Country:US
Mailing Address - Phone:818-468-9967
Mailing Address - Fax:
Practice Address - Street 1:2777 BRISTOL ST STE B
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5997
Practice Address - Country:US
Practice Address - Phone:949-250-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302071225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty