Healthcare Provider Details

I. General information

NPI: 1245157908
Provider Name (Legal Business Name): CARLY WEAVER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 CENTRE ST
JAMAICA PLAIN MA
02130-1831
US

IV. Provider business mailing address

441 CENTRE ST
JAMAICA PLAIN MA
02130-1831
US

V. Phone/Fax

Practice location:
  • Phone: 617-522-8086
  • Fax:
Mailing address:
  • Phone: 617-522-8086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: