Provider Demographics
NPI:1609944818
Name:WEIDL, LYNNE M (PT)
Entity type:Individual
Prefix:MRS
First Name:LYNNE
Middle Name:M
Last Name:WEIDL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 DENSLOW RD
Mailing Address - Street 2:
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-3103
Mailing Address - Country:US
Mailing Address - Phone:413-526-9969
Mailing Address - Fax:413-526-9960
Practice Address - Street 1:80 DENSLOW RD
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-3103
Practice Address - Country:US
Practice Address - Phone:413-526-9969
Practice Address - Fax:413-526-9960
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8426225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY67404OtherBCBS
MAPT0191Medicare PIN
MAY67404OtherBCBS