MEDICARE: KELLY M. WEAVER, PH.D., INC.

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	103T00000X	Psychologist	5796	OH

General Provider Information

NPI Number	:	1770678146
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLY M. WEAVER, PH.D., INC.

Provider Business Mailing Address
First Line	:	3011 BETHEL RD
Second Line	:	SUITE 100
City	:	COLUMBUS
State	:	OH
Zip	:	43220-6104
Country	:	US
Telephone Number	:	614-459-2156
Fax Number	:	614-451-1381

Provider Business Practice Location Address
First Line	:	3011 BETHEL RD
Second Line	:	SUITE 100
City	:	COLUMBUS
State	:	OH
Zip	:	43220-6104
Country	:	US
Telephone Number	:	614-459-2156
Fax Number	:	614-451-1381

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KELLY M. WEAVER
Credential	:	PH.D.
Telephone Number	:	614-459-2156

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	06/09/2008

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