Provider Demographics
NPI:1205009651
Name:WEAVER, MICHELLE R (MS ED)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:R
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 MILES ST APT 9
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-6367
Mailing Address - Country:US
Mailing Address - Phone:214-435-1240
Mailing Address - Fax:214-631-6698
Practice Address - Street 1:8625 KING GEORGE DR STE 111
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-2240
Practice Address - Country:US
Practice Address - Phone:214-631-7002
Practice Address - Fax:214-631-6698
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19549101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional