Healthcare Provider Details

I. General information

NPI: 1780343202
Provider Name (Legal Business Name): MARK ALAN WEEDON LMFT-A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2021
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2490 BOONVILLE RD
BRYAN TX
77808-2326
US

IV. Provider business mailing address

5273 FM 1179
BRYAN TX
77808-7248
US

V. Phone/Fax

Practice location:
  • Phone: 979-571-6216
  • Fax:
Mailing address:
  • Phone: 979-571-6216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number204063
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: