Provider Demographics
NPI:1508607169
Name:WEASE, MISTY
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:WEASE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2396 FRIENDSHIP CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:KY
Mailing Address - Zip Code:42757-7613
Mailing Address - Country:US
Mailing Address - Phone:270-218-2652
Mailing Address - Fax:
Practice Address - Street 1:2396 FRIENDSHIP CHURCH RD
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:KY
Practice Address - Zip Code:42757-7613
Practice Address - Country:US
Practice Address - Phone:270-218-2652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility