Healthcare Provider Details

I. General information

NPI: 1427196179
Provider Name (Legal Business Name): KYLEAN WEAVER M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N EL CENTRO AVE
LOS ANGELES CA
90038-3805
US

IV. Provider business mailing address

2312 4TH AVE
LOS ANGELES CA
90018-1845
US

V. Phone/Fax

Practice location:
  • Phone: 323-769-7150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number171M00000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: