Provider Demographics
NPI:1255927067
Name:WEAVER, KATIE LEE (LMT)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LEE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 E SELTICE WAY
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7022
Mailing Address - Country:US
Mailing Address - Phone:208-777-0128
Mailing Address - Fax:
Practice Address - Street 1:1624 E SELTICE WAY
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7022
Practice Address - Country:US
Practice Address - Phone:208-777-0128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-2956225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMAS-2956OtherBUREAU OF OCCUPATIONAL LICENSE