Provider Demographics
NPI:1174657134
Name:WEAVER, KEVIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:WEAVER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E GRISWOLD RD UNIT 20
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-3777
Mailing Address - Country:US
Mailing Address - Phone:602-997-7897
Mailing Address - Fax:602-997-7894
Practice Address - Street 1:1001 E GRISWOLD RD UNIT 20
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3777
Practice Address - Country:US
Practice Address - Phone:602-997-7897
Practice Address - Fax:602-997-7894
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1215103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical