Provider Demographics
NPI:1831411529
Name:WEIBLE, STACY (AT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WEIBLE
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:DILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AT
Mailing Address - Street 1:781 SUMTER ST
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-8539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:781 SUMTER ST
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:OH
Practice Address - Zip Code:43119-8539
Practice Address - Country:US
Practice Address - Phone:440-724-5277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT. 0032172255A2300X
OHPT.014269225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer