Provider Demographics
NPI:1356717748
Name:WEBER, RENEE A (DPT)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:A
Last Name:WEBER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:A
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:620 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5299
Mailing Address - Country:US
Mailing Address - Phone:208-419-3408
Mailing Address - Fax:208-419-3412
Practice Address - Street 1:620 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5299
Practice Address - Country:US
Practice Address - Phone:208-419-3408
Practice Address - Fax:208-419-3412
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-4146225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist