=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003205741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESPAN PSYCHOLOGY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2015
-----------------------------------------------------
Last Update Date | 01/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 98 VOORHEES RD E
-----------------------------------------------------
City | HAMILTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31811-5671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-260-0361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 98 VOORHEES RD E
-----------------------------------------------------
City | HAMILTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31811-5671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-582-3647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHAIRMAN
-----------------------------------------------------
Name | DR. KEVIN JAMES WEIS
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 954-260-0361
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PSY003141
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PSY003142
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------