Provider Demographics
NPI:1467873588
Name:WEAVER, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:WEAVER
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 1:610 E COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:812 E JOLLY RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-6818
Practice Address - Country:US
Practice Address - Phone:517-346-9522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013781101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional