Healthcare Provider Details

I. General information

NPI: 1073909511
Provider Name (Legal Business Name): WEATHERBY & ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 04/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 N WASHINGTON ST
MEXICO MO
65265-3352
US

IV. Provider business mailing address

1323 N WASHINGTON ST
MEXICO MO
65265-3352
US

V. Phone/Fax

Practice location:
  • Phone: 573-470-6826
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JUSTIN RAY WEATHERBY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 573-784-0819