Provider Demographics
NPI:1508328212
Name:WEAVER, ELLIS (LMHC)
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 MOORE ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2421
Mailing Address - Country:US
Mailing Address - Phone:203-654-1531
Mailing Address - Fax:
Practice Address - Street 1:53 CHESTER ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-3001
Practice Address - Country:US
Practice Address - Phone:203-654-1531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11190101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty