Basic Information
| Provider Information | |||||||||
| NPI: | 1104554369 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEIS | ||||||||
| FirstName: | COURTNEY | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 KENMOOR AVE SE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495462395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163565000 | ||||||||
| FaxNumber: | 6163565001 | ||||||||
| Practice Location | |||||||||
| Address1: | 22342 W 66TH ST | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662263560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137286166 | ||||||||
| FaxNumber: | 8336158216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2022 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11-07114 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.