Provider Demographics
NPI:1114243342
Name:WEAVER, KATHRYN JO (LCSW & LAT)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:JO
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LCSW & LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 NAVAJO TRL
Mailing Address - Street 2:
Mailing Address - City:BISBEE
Mailing Address - State:AZ
Mailing Address - Zip Code:85603-1639
Mailing Address - Country:US
Mailing Address - Phone:307-752-7678
Mailing Address - Fax:
Practice Address - Street 1:101 N CORONADO DR STE A
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-6359
Practice Address - Country:US
Practice Address - Phone:520-343-2940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT-305101YA0400X
WYLCSW-5791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)