Healthcare Provider Details

I. General information

NPI: 1891020004
Provider Name (Legal Business Name): TIMOTHY L WEAVER L.M.H.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11736 NEWBERRY GROVE LOOP
RIVERVIEW FL
33579-3902
US

IV. Provider business mailing address

11736 NEWBERRY GROVE LOOP
RIVERVIEW FL
33579-3902
US

V. Phone/Fax

Practice location:
  • Phone: 908-415-0632
  • Fax:
Mailing address:
  • Phone: 908-415-0632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 9939
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: