Healthcare Provider Details

I. General information

NPI: 1669543658
Provider Name (Legal Business Name): WEAVER CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 BOSTON POST RD
WESTON MA
02493-2543
US

IV. Provider business mailing address

158 BOSTON POST RD
WESTON MA
02493-2543
US

V. Phone/Fax

Practice location:
  • Phone: 781-894-4561
  • Fax:
Mailing address:
  • Phone: 781-894-4561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY 3083 PR
License Number StateMA

VIII. Authorized Official

Name: DR. ROBERT A WEAVER III
Title or Position: DIRECTOR
Credential: PH.D.
Phone: 781-894-4561