Provider Demographics
NPI:1700089836
Name:WIEBERG, DAPHNE
Entity Type:Individual
Prefix:
First Name:DAPHNE
Middle Name:
Last Name:WIEBERG
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 1:185 GOTT PLANTATION RD
Mailing Address - Street 2:
Mailing Address - City:ULMAN
Mailing Address - State:MO
Mailing Address - Zip Code:65083-2018
Mailing Address - Country:US
Mailing Address - Phone:573-280-4586
Mailing Address - Fax:
Practice Address - Street 1:1030 EDMONDS ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5213
Practice Address - Country:US
Practice Address - Phone:615-896-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004015187225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant