Healthcare Provider Details

I. General information

NPI: 1821051210
Provider Name (Legal Business Name): MICHELLE WEIDNER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4614 S 132ND ST
OMAHA NE
68137-1764
US

IV. Provider business mailing address

9447B LORTON MARKET ST #250
LORTON VA
22079-1963
US

V. Phone/Fax

Practice location:
  • Phone: 402-330-3211
  • Fax:
Mailing address:
  • Phone: 703-372-5716
  • Fax: 703-372-5718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3325
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305208560
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3683
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: