Provider Demographics
NPI:1477087740
Name:WEEDEN, COLLIN
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:WEEDEN
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 1:3419 VIA LIDO # 309
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3908
Mailing Address - Country:US
Mailing Address - Phone:949-675-3764
Mailing Address - Fax:
Practice Address - Street 1:3419 VIA LIDO # 309
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3908
Practice Address - Country:US
Practice Address - Phone:949-675-3764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician