Provider Demographics
NPI:1780097550
Name:WEATHERTON, DESTINY NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:NICOLE
Last Name:WEATHERTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11300 EXPO BLVD APT 1014
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1333
Mailing Address - Country:US
Mailing Address - Phone:817-456-2600
Mailing Address - Fax:
Practice Address - Street 1:98 BRIGGS ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-1286
Practice Address - Country:US
Practice Address - Phone:210-226-9536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2096703225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant