Provider Demographics
NPI:1194421354
Name:WEISNER, MICHELLE (COTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WEISNER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 GINGER DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:TN
Mailing Address - Zip Code:37058-3652
Mailing Address - Country:US
Mailing Address - Phone:573-450-1053
Mailing Address - Fax:
Practice Address - Street 1:314 GINGER DR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:TN
Practice Address - Zip Code:37058-3652
Practice Address - Country:US
Practice Address - Phone:573-450-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3857224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant