Basic Information
| Provider Information | |||||||||
| NPI: | 1255712972 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEYRAUCH | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANDVICK | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1560 S CAROL ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836461839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 HIGHWAY 59 S | ||||||||
| Address2: | SUITE A | ||||||||
| City: | THIEF RIVER FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567013413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186810449 | ||||||||
| FaxNumber: | 2186810490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2015 | ||||||||
| LastUpdateDate: | 08/26/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-10022 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT-10022 | 01 | MN | MN LICENSE | OTHER |