Provider Demographics
NPI:1386895894
Name:WEAVER, KRISTEN M (MS, PT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11711 NE 12TH ST
Mailing Address - Street 2:STE 3A
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2461
Mailing Address - Country:US
Mailing Address - Phone:425-450-9474
Mailing Address - Fax:425-452-0704
Practice Address - Street 1:1445 GALAXY DR NE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516
Practice Address - Country:US
Practice Address - Phone:360-456-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011977225100000X
WAPT60041800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501011977OtherMICHIGAN STATE LICENSE
WA1386895894Medicaid
WA2002864Medicaid
WA2002864Medicaid