Provider Demographics
NPI:1336500107
Name:WEBER, MARK TIMOTHY
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:TIMOTHY
Last Name:WEBER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 ROBIN LN
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:TX
Mailing Address - Zip Code:76574-1374
Mailing Address - Country:US
Mailing Address - Phone:717-413-8398
Mailing Address - Fax:
Practice Address - Street 1:2100 ROBIN LN
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:TX
Practice Address - Zip Code:76574-1374
Practice Address - Country:US
Practice Address - Phone:717-413-8398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70039101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor