=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295049294
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISTY WEAVER LPC, CMHT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2010
-----------------------------------------------------
Last Update Date | 08/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 S CASS ST
-----------------------------------------------------
City | CORINTH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38834-6109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-286-9860
-----------------------------------------------------
Fax | 662-286-8095
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 839 301 CASS ST
-----------------------------------------------------
City | CORINTH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38835-0839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-286-9860
-----------------------------------------------------
Fax | 662-286-8095
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2113
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 2368
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------