MEDICARE: SHANTELE K WEAVER 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
1	101YP2500X	Professional Counselor	22276	NC
2	101YM0800X	Mental Health Counselor	PC018916	PA
3	101YM0800X	Mental Health Counselor	22276	NC

General Provider Information

NPI Number	:	1780566059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTELE K WEAVER LPC

Provider Business Mailing Address
First Line	:	855 SAM NEWELL RD STE 100
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-7593
Country	:	US
Telephone Number	:	704-360-3637
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 SAM NEWELL RD STE 100
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-7593
Country	:	US
Telephone Number	:	704-360-3637
Fax Number	:

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

Provider Enumeration Date	:	07/25/2025
Last Update Date	:	12/17/2025

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