Healthcare Provider Details

I. General information

NPI: 1629587340
Provider Name (Legal Business Name): GRACE ANNE WEISBECKER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 09/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 WOODS RD
TIVOLI NY
12583-5429
US

IV. Provider business mailing address

6 WOODS RD
TIVOLI NY
12583-5429
US

V. Phone/Fax

Practice location:
  • Phone: 845-798-2525
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number003450-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: