Healthcare Provider Details

I. General information

NPI: 1932682200
Provider Name (Legal Business Name): DOUGLAS PAUL WEAVER JR. LCSW, CCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 04/23/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MOLLISON WAY
LEWISTON ME
04240
US

IV. Provider business mailing address

20 MOLLISON WAY
LEWISTON ME
04240
US

V. Phone/Fax

Practice location:
  • Phone: 207-468-2047
  • Fax: 207-645-2372
Mailing address:
  • Phone: 207-467-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC20836
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: