MEDICARE: IRENE WEAVER

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	6409	CA

General Provider Information

NPI Number	:	1689890238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRENE WEAVER

Provider Business Mailing Address
First Line	:	3337 E PONTIAC WAY
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93726-4416
Country	:	US
Telephone Number	:	559-281-2451
Fax Number	:

Provider Business Practice Location Address
First Line	:	1410 F ST STE 101
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93706-1608
Country	:	US
Telephone Number	:	559-457-2302
Fax Number	:

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	09/20/2019

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Directions to “ IRENE WEAVER ” Practice Location

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