MEDICARE: PAULA CELESTE WEAVER LAC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1265133433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULA CELESTE WEAVER LAC

Provider Business Mailing Address
First Line	:	3326 CROWE HILL CIR
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5933
Country	:	US
Telephone Number	:	479-806-7703
Fax Number	:

Provider Business Practice Location Address
First Line	:	3326 CROWE HILL CIR
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5933
Country	:	US
Telephone Number	:	479-806-7703
Fax Number	:

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

Provider Enumeration Date	:	03/15/2023
Last Update Date	:	03/15/2023

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