Provider Demographics
NPI:1053580076
Name:WEAVER, TERRY M (PTA)
Entity type:Individual
Prefix:MS
First Name:TERRY
Middle Name:M
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 W 300 S
Mailing Address - Street 2:
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-8355
Mailing Address - Country:US
Mailing Address - Phone:574-946-3957
Mailing Address - Fax:
Practice Address - Street 1:616 E 13TH ST
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1117
Practice Address - Country:US
Practice Address - Phone:574-946-2157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-24
Last Update Date:2008-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06001957A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant