Healthcare Provider Details

I. General information

NPI: 1053878975
Provider Name (Legal Business Name): KEITH W WEAVER MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 W 1700 S
OREM UT
84058-7542
US

IV. Provider business mailing address

19999 DOTTIE LN
PRINCETON MO
64673-8023
US

V. Phone/Fax

Practice location:
  • Phone: 801-610-9313
  • Fax:
Mailing address:
  • Phone: 801-688-8240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2022013753
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number096467
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberTH00946205
License Number StateWV
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number323944-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier096467
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerLCSW NY LICENSING
# 2
Identifier2022013753
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerLICENSED CLINICAL SOCIAL WORKER
# 3
IdentifierTH00946205
Identifier TypeOTHER
Identifier StateWV
Identifier IssuerLCSW - WV LICENSING
# 4
Identifier323944-3501
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerSTATE OF UTAH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: