Basic Information
| Provider Information | |||||||||
| NPI: | 1386895894 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WEAVER | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.S., P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11711 NE 12TH ST | ||||||||
| Address2: | STE 3A | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980052461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254509474 | ||||||||
| FaxNumber: | 4254520704 | ||||||||
| Practice Location | |||||||||
| Address1: | 1445 GALAXY DR NE | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604561444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501011977 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT60041800 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5501011977 | 01 | MI | MICHIGAN STATE LICENSE | OTHER | 1386895894 | 05 | WA | MEDICAID | 2002864 | 05 | WA | MEDICAID |