Provider Demographics
NPI:1821051210
Name:WEIDNER, MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WEIDNER
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 1:9447B LORTON MARKET ST
Mailing Address - Street 2:#250
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1963
Mailing Address - Country:US
Mailing Address - Phone:703-372-5716
Mailing Address - Fax:703-372-5718
Practice Address - Street 1:4614 S 132ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1764
Practice Address - Country:US
Practice Address - Phone:402-330-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3325225100000X
VA2305208560225100000X
NE3683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47065477701Medicaid