Provider Demographics
NPI:1104222504
Name:WEAVER, TERESSA
Entity Type:Individual
Prefix:
First Name:TERESSA
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 1:9126 COUNTY ROAD 310
Mailing Address - Street 2:
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75161-7104
Mailing Address - Country:US
Mailing Address - Phone:972-835-3762
Mailing Address - Fax:
Practice Address - Street 1:9126 COUNTY ROAD 310
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75161-7104
Practice Address - Country:US
Practice Address - Phone:972-835-3762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX636194171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator