=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225816796
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY WEIBERG LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2023
-----------------------------------------------------
Last Update Date | 09/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 DEAN ST STE E
-----------------------------------------------------
City | ST CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60174-1665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-442-4048
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3163 RIVERBIRCH DR APT 204
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60502-7152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-981-1533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 227.019340
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------