Provider Demographics
NPI:1295629855
Name:WEBER, MANDIE (LMT)
Entity type:Individual
Prefix:
First Name:MANDIE
Middle Name:
Last Name:WEBER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 106TH AVE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MI
Mailing Address - Zip Code:49078-9763
Mailing Address - Country:US
Mailing Address - Phone:269-355-5875
Mailing Address - Fax:269-355-5875
Practice Address - Street 1:1727 106TH AVE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MI
Practice Address - Zip Code:49078-9763
Practice Address - Country:US
Practice Address - Phone:269-355-5875
Practice Address - Fax:269-355-5875
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501011694225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist