Provider Demographics
NPI:1164642922
Name:WEISS, MARY ELIZABETH (MA, LMHC, LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:WEISS
Suffix:
Gender:F
Credentials:MA, LMHC, LPC
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:RUBLE TWARDOKUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2222 COLONIAL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-5309
Mailing Address - Country:US
Mailing Address - Phone:772-489-4726
Mailing Address - Fax:772-489-0423
Practice Address - Street 1:2222 COLONIAL RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-5309
Practice Address - Country:US
Practice Address - Phone:772-489-4726
Practice Address - Fax:727-489-0423
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010213101Y00000X
FLMH14480101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020817400Medicaid