MEDICARE: MRS. THERESA M. WEAVER M.A., L.P.C.

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
1	101YP2500X	Professional Counselor	6401004225	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12443729	OTHER	MI	CAQH

General Provider Information

NPI Number	:	1255393401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. THERESA M. WEAVER M.A., L.P.C.

Provider Business Mailing Address
First Line	:	200 S WENONA ST
Second Line	:	DEPT-TOTAL FAMILY HEALTH CARE STE 170
City	:	BAY CITY
State	:	MI
Zip	:	48706-8820
Country	:	US
Telephone Number	:	989-893-6162
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 S WENONA ST
Second Line	:	DEPT-TOTAL FAMILY HEALTH CARE STE 170
City	:	BAY CITY
State	:	MI
Zip	:	48706-8820
Country	:	US
Telephone Number	:	989-893-6162
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2006
Last Update Date	:	02/23/2015

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