Healthcare Provider Details

I. General information

NPI: 1740341528
Provider Name (Legal Business Name): DANIEL TODD WEAVER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 COUNTY ROAD 120 SUITE A
SAINT CLOUD MN
56303
US

IV. Provider business mailing address

1301 33RD ST S STE 210
SAINT CLOUD MN
56301-9668
US

V. Phone/Fax

Practice location:
  • Phone: 320-259-5429
  • Fax: 320-240-8905
Mailing address:
  • Phone: 320-240-6955
  • Fax: 320-240-8089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6148
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: