MEDICARE: GERARDA THERESA WEIS LCSW

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	1041C0700X	Clinical Social Worker	001280	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	011869	OTHER	A/B NETWORK PROVIDER
2	27033	OTHER	COMPSYCH NETWORK PROVIDER
3	100879	OTHER	BCBS NETWORK PROVIDER

General Provider Information

NPI Number	:	1922117647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERARDA THERESA WEIS LCSW

Provider Business Mailing Address
First Line	:	10000 WATSON RD # 2L18
Second Line	:	PERSONAL POTENTIALS INC
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-1854
Country	:	US
Telephone Number	:	314-822-4727
Fax Number	:	314-822-0531

Provider Business Practice Location Address
First Line	:	10000 WATSON RD # 2L18
Second Line	:	PERSONAL POTENTIALS INC
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-1854
Country	:	US
Telephone Number	:	314-822-4727
Fax Number	:	314-822-0531

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

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	10/07/2008

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