Provider Demographics
NPI:1063640365
Name:WEAVER, ALLISON (LADC)
Entity Type:Individual
Prefix:MS
First Name:ALLISON
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4267 TWIN RIVER WAY
Mailing Address - Street 2:1427
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-2829
Mailing Address - Country:US
Mailing Address - Phone:202-520-4916
Mailing Address - Fax:
Practice Address - Street 1:4267 TWIN RIVER WAY
Practice Address - Street 2:1427
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-2829
Practice Address - Country:US
Practice Address - Phone:202-520-4916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK00027101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)