Provider Demographics
NPI:1215612072
Name:WEISMAN, MACKENZIE (DPT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:WEISMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 VALLEY RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-8416
Mailing Address - Country:US
Mailing Address - Phone:952-484-9276
Mailing Address - Fax:
Practice Address - Street 1:913 11TH ST SE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9168
Practice Address - Country:US
Practice Address - Phone:541-347-4314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13066225100000X
OR65015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist