Provider Demographics
NPI:1023076346
Name:WEAVER, LAURIE ELAINE (LPT)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ELAINE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1827
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43301-1827
Mailing Address - Country:US
Mailing Address - Phone:740-383-8022
Mailing Address - Fax:740-383-7942
Practice Address - Street 1:1050 DELAWARE AVENUE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302
Practice Address - Country:US
Practice Address - Phone:740-383-8022
Practice Address - Fax:740-383-7942
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT010063225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000242859OtherANTHEM
OH2369011Medicaid
311704991OtherUNITED MINEWORKERS OF AM
650024871OtherTRAVELERS MEDICARE
P66764Medicare UPIN
OH2369011Medicaid