Provider Demographics
NPI:1760345151
Name:WEITKAMP, TERENA
Entity type:Individual
Prefix:
First Name:TERENA
Middle Name:
Last Name:WEITKAMP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51728 STATE HWY 933
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637
Mailing Address - Country:US
Mailing Address - Phone:419-348-7995
Mailing Address - Fax:574-217-4589
Practice Address - Street 1:5737 S IRONWOOD RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-9668
Practice Address - Country:US
Practice Address - Phone:419-348-7995
Practice Address - Fax:574-217-4589
Is Sole Proprietor?:No
Enumeration Date:2025-12-03
Last Update Date:2025-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39005538A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health