Provider Demographics
NPI:1831788462
Name:WEAVER, ELIZABETH ANN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:ANN
Other - Last Name:FRY/MACEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPT
Mailing Address - Street 1:GENERAL DELIVERY
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-9999
Mailing Address - Country:US
Mailing Address - Phone:913-378-3216
Mailing Address - Fax:
Practice Address - Street 1:6416 LONG AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66216-2566
Practice Address - Country:US
Practice Address - Phone:913-839-8563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01634224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty