=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386074789
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAWNA LEE WEAVER LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2013
-----------------------------------------------------
Last Update Date | 03/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 EAST LANCASTER AVENUE SUITE #200
-----------------------------------------------------
City | WYNNEWOOD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-268-7055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 335 DRESHERTOWN ROAD
-----------------------------------------------------
City | FORT WASHINGTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CW017749
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------