Provider Demographics
NPI:1699434951
Name:WEAVER, MIKAEA JOELLE (OTR)
Entity type:Individual
Prefix:
First Name:MIKAEA
Middle Name:JOELLE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14409 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:OK
Mailing Address - Zip Code:73078-8910
Mailing Address - Country:US
Mailing Address - Phone:620-453-2467
Mailing Address - Fax:
Practice Address - Street 1:1824 COMMONS CIR STE B
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-9538
Practice Address - Country:US
Practice Address - Phone:405-467-6782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK464768225X00000X
OK5639225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist