Provider Demographics
NPI:1376130021
Name:WEAVER, KEILEISHA LOUISE
Entity Type:Individual
Prefix:
First Name:KEILEISHA
Middle Name:LOUISE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 COPPER DR APT 23
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-4426
Mailing Address - Country:US
Mailing Address - Phone:760-215-7839
Mailing Address - Fax:
Practice Address - Street 1:2271 ALPINE BLVD STE A
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-1101
Practice Address - Country:US
Practice Address - Phone:619-289-7322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC8212101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor