Provider Demographics
NPI:1942978762
Name:WEAVER, MALLORY (PTA)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 BUNNY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-8833
Mailing Address - Country:US
Mailing Address - Phone:717-507-7269
Mailing Address - Fax:
Practice Address - Street 1:333 WHEAT RIDGE DR
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-8558
Practice Address - Country:US
Practice Address - Phone:717-354-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI003986225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant