MEDICARE: MS. ALLISON WEAVER L.A.D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	00027	OK

General Provider Information

NPI Number	:	1063640365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ALLISON WEAVER L.A.D.C.

Provider Business Mailing Address
First Line	:	4267 TWIN RIVER WAY
Second Line	:	1427
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84123-2829
Country	:	US
Telephone Number	:	202-520-4916
Fax Number	:

Provider Business Practice Location Address
First Line	:	4267 TWIN RIVER WAY
Second Line	:	1427
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84123-2829
Country	:	US
Telephone Number	:	202-520-4916
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2009
Last Update Date	:	06/24/2009

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