Provider Demographics
NPI:1740893510
Name:WEIDNER, ELISE A
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:A
Last Name:WEIDNER
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 1:1949 HIGHWAY 81 STE 100
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-4583
Mailing Address - Country:US
Mailing Address - Phone:770-207-6390
Mailing Address - Fax:
Practice Address - Street 1:1949 HIGHWAY 81 STE 100
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4583
Practice Address - Country:US
Practice Address - Phone:770-207-6390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT007833OtherPROFESSIONAL LICENSE