Provider Demographics
NPI:1477067478
Name:WEAVER, SAMANTHA RENEE (BCBA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RENEE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 CHESTER VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-1782
Mailing Address - Country:US
Mailing Address - Phone:804-544-9044
Mailing Address - Fax:804-715-4789
Practice Address - Street 1:11800 CHESTER VILLAGE DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1782
Practice Address - Country:US
Practice Address - Phone:804-544-9044
Practice Address - Fax:804-715-4789
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1-21-52785103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-21-52785OtherBACB
VA0133002582OtherVIRGINIA DEPARTMENT OF HEALTH PROFESSIONS - BOARD OF MEDICINE