Provider Demographics
NPI:1215107776
Name:WEAVER, DIANE MARIE (PT)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:CHAMBERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:611 W PARK
Mailing Address - Street 2:FAPC
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61802
Mailing Address - Country:US
Mailing Address - Phone:217-902-6954
Mailing Address - Fax:217-902-7711
Practice Address - Street 1:1111 TRINITY LN STE 111
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8112
Practice Address - Country:US
Practice Address - Phone:309-608-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18133225100000X
WI11334-024225100000X
IL070017881225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1215107776Medicaid
WI1215107776Medicaid