Provider Demographics
NPI:1235381807
Name:WEAVER, MATTHEW ROGER (LMT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ROGER
Last Name:WEAVER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 TEAL ROAD
Mailing Address - Street 2:
Mailing Address - City:SAND LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12153
Mailing Address - Country:US
Mailing Address - Phone:518-674-4033
Mailing Address - Fax:
Practice Address - Street 1:1523 COLUMBIA TURNPIKE
Practice Address - Street 2:SERENITY DAY SPA
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9544
Practice Address - Country:US
Practice Address - Phone:518-479-5680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013854-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist