Provider Demographics
NPI:1184391864
Name:WEIDMAN, ALLYSE
Entity type:Individual
Prefix:
First Name:ALLYSE
Middle Name:
Last Name:WEIDMAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 ALFA CT APT 2A
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-2982
Mailing Address - Country:US
Mailing Address - Phone:734-649-4294
Mailing Address - Fax:
Practice Address - Street 1:5228 LOVERS LN STE 102
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1521
Practice Address - Country:US
Practice Address - Phone:734-649-4284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIW355051229356OtherBEHAVIOR ANALYST