Healthcare Provider Details

I. General information

NPI: 1376816405
Provider Name (Legal Business Name): COURTNEY WEAVER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: COURTNEY LUONGO LCSW

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43130 AMBERWOOD PLZ SUITE 140
SOUTH RIDING VA
20152-4105
US

IV. Provider business mailing address

43130 AMBERWOOD PLZ SUITE 140
SOUTH RIDING VA
20152-4105
US

V. Phone/Fax

Practice location:
  • Phone: 703-348-0030
  • Fax:
Mailing address:
  • Phone: 703-348-0030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904008780
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: