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NPI Code Detail

MEDICARE: MRS. KELLY JEAN WEAVER MED, EDS, LPC

MEDICARE: MRS. KELLY JEAN WEAVER MED, EDS, LPC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YP2500XProfessional Counselor2760SC

General Provider Information

NPI Number : 1063594034
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KELLY JEAN WEAVER MED, EDS, LPC
Provider Business Mailing Address
First Line : 224 E MAIN ST
Second Line :
City : LEXINGTON
State : SC
Zip : 29072-3546
Country : US
Telephone Number : 803-808-5222
Fax Number : 803-957-2042
Provider Business Practice Location Address
First Line : 224 E MAIN ST
Second Line :
City : LEXINGTON
State : SC
Zip : 29072-3546
Country : US
Telephone Number : 803-808-5222
Fax Number : 803-957-2042
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/19/2006
Last Update Date : 07/08/2007

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