Provider Demographics
NPI:1851819775
Name:WEIGAND, MICHAEL REEVES (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:REEVES
Last Name:WEIGAND
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 TERMINO AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-7508
Mailing Address - Country:US
Mailing Address - Phone:330-931-1610
Mailing Address - Fax:
Practice Address - Street 1:273 E BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3775
Practice Address - Country:US
Practice Address - Phone:323-724-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17836225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17836Medicaid