Provider Demographics
NPI:1861857146
Name:WEIDEMAN, ELIZABETH (PT, DPT, LMT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WEIDEMAN
Suffix:
Gender:F
Credentials:PT, DPT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11101 NE 14TH ST STE 108
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4366
Mailing Address - Country:US
Mailing Address - Phone:360-254-1232
Mailing Address - Fax:360-254-5188
Practice Address - Street 1:1050 W ELM AVE STE 130
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2713
Practice Address - Country:US
Practice Address - Phone:541-567-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60445388225700000X
OR63465225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist