Provider Demographics
NPI:1275575334
Name:WEAVER, KELLY M (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 BETHEL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-6104
Mailing Address - Country:US
Mailing Address - Phone:614-459-2156
Mailing Address - Fax:
Practice Address - Street 1:3011 BETHEL RD STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-6104
Practice Address - Country:US
Practice Address - Phone:614-459-2156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5796103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCP28881Medicare ID - Type Unspecified
OH2399588Medicare ID - Type Unspecified