=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750556874
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIE WEAVER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2008
-----------------------------------------------------
Last Update Date | 08/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5312 JAGUAR DR
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87507-1827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-820-0262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 724 POSTAL SERVICE LOOP # 1025 BLDG 1108, 2ND FLOOR
-----------------------------------------------------
City | JBER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99505-5001
-----------------------------------------------------
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 | I-08011
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------