Provider Demographics
NPI:1649555988
Name:WEATHERLY, ERIC DEAN (DPT)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:DEAN
Last Name:WEATHERLY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 OLD SHED RD STE 7
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2820
Mailing Address - Country:US
Mailing Address - Phone:318-417-0108
Mailing Address - Fax:318-283-0606
Practice Address - Street 1:3867 BAYOU ACRES DR
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-9232
Practice Address - Country:US
Practice Address - Phone:318-283-2080
Practice Address - Fax:318-283-0606
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07702174400000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist