Healthcare Provider Details

I. General information

NPI: 1144115619
Provider Name (Legal Business Name): TYLER WAYNE WEAVER AU.D., CCC-A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 RIVER OAKS DR STE 120
SOUTHLAKE TX
76092-7087
US

IV. Provider business mailing address

5600 BOVINE DR APT 9106
FORT WORTH TX
76244-0047
US

V. Phone/Fax

Practice location:
  • Phone: 972-745-8400
  • Fax:
Mailing address:
  • Phone: 662-202-8204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number81764
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: