Healthcare Provider Details

I. General information

NPI: 1497580997
Provider Name (Legal Business Name): SAMUEL WEIBLE CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EXECUTIVE PARK STE 103
LOUISVILLE KY
40207-4201
US

IV. Provider business mailing address

4800 N SCOTTSDALE RD STE 2500
SCOTTSDALE AZ
85251-7630
US

V. Phone/Fax

Practice location:
  • Phone: 888-585-8434
  • Fax: 216-456-8128
Mailing address:
  • Phone: 888-585-8434
  • Fax: 216-456-8128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCSW00001579
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: