Healthcare Provider Details

I. General information

NPI: 1750556874
Provider Name (Legal Business Name): JULIE WEAVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5312 JAGUAR DR
SANTA FE NM
87507-1827
US

IV. Provider business mailing address

724 POSTAL SERVICE LOOP # 1025 BLDG 1108, 2ND FLOOR
JBER AK
99505-5001
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-0262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-08011
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: