Provider Demographics
NPI:1255712972
Name:WEYRAUCH, STEPHANIE A (DPT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:WEYRAUCH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:A
Other - Last Name:SANDVICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1560 S CAROL ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1839
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:208-287-9426
Practice Address - Street 1:1511 HIGHWAY 59 S
Practice Address - Street 2:SUITE A
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-3413
Practice Address - Country:US
Practice Address - Phone:218-681-0449
Practice Address - Fax:218-681-0490
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNPT-10022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNPT-10022OtherMN LICENSE