Healthcare Provider Details

I. General information

NPI: 1104371046
Provider Name (Legal Business Name): AMANDA WEAVER LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2016
Last Update Date: 08/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 W MADISON ST #11
BALTIMORE MD
21201-5239
US

IV. Provider business mailing address

4602 SCHENLEY RD
BALTIMORE MD
21210-2526
US

V. Phone/Fax

Practice location:
  • Phone: 443-438-7863
  • Fax:
Mailing address:
  • Phone: 410-205-9782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC7221
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: