Provider Demographics
NPI:1043647852
Name:WEAVER, VENIS
Entity Type:Individual
Prefix:
First Name:VENIS
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 W 3940 S # EW11
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5757
Mailing Address - Country:US
Mailing Address - Phone:801-694-4104
Mailing Address - Fax:801-905-1161
Practice Address - Street 1:5667 S REDWOOD RD UNIT 6B
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5495
Practice Address - Country:US
Practice Address - Phone:801-694-4104
Practice Address - Fax:801-905-1161
Is Sole Proprietor?:No
Enumeration Date:2013-10-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT379328-3503104100000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No104100000XBehavioral Health & Social Service ProvidersSocial Worker