Provider Demographics
NPI:1467426601
Name:WEAGLEY, JOHN (LCSW,LCADC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WEAGLEY
Suffix:
Gender:M
Credentials:LCSW,LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 228
Mailing Address - Street 2:
Mailing Address - City:PLUCKEMIN
Mailing Address - State:NJ
Mailing Address - Zip Code:07978-0228
Mailing Address - Country:US
Mailing Address - Phone:201-715-8694
Mailing Address - Fax:908-304-0777
Practice Address - Street 1:99 BEAUVOIR AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3533
Practice Address - Country:US
Practice Address - Phone:973-971-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC00577400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ423568AUKMedicare ID - Type Unspecified
NJS32842Medicare UPIN