Healthcare Provider Details

I. General information

NPI: 1508928680
Provider Name (Legal Business Name): MARK SHANNON WEAVER MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 YONKERS RD
RALEIGH NC
27604-2258
US

IV. Provider business mailing address

104 ASHLEY RD
APEX NC
27539-9353
US

V. Phone/Fax

Practice location:
  • Phone: 919-896-7536
  • Fax:
Mailing address:
  • Phone: 919-327-8730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3471
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3471
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: