=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447996137
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST MARIN PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2022
-----------------------------------------------------
Last Update Date | 05/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11431 STATE ROUTE 1 SUITE 9
-----------------------------------------------------
City | POINT REYES STATION
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94956-1264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-663-9216
-----------------------------------------------------
Fax | 415-663-9216
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1264
-----------------------------------------------------
City | POINT REYES STATION
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94956-1264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-663-9216
-----------------------------------------------------
Fax | 415-663-9216
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PHYSICAL THERAPIST
-----------------------------------------------------
Name | FREDA WEITZER
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 415-663-9216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------