Provider Demographics
NPI:1982941860
Name:WEAVER, ANGELA M (OT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:WEAVER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:NEUENFELDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1245 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3905
Mailing Address - Country:US
Mailing Address - Phone:218-846-7013
Mailing Address - Fax:218-846-7015
Practice Address - Street 1:1245 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3905
Practice Address - Country:US
Practice Address - Phone:218-846-7013
Practice Address - Fax:218-846-7015
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102587225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND56156Medicaid