Provider Demographics
NPI:1508917980
Name:WEAVER, AVA N (MS, NCC,LPC)
Entity Type:Individual
Prefix:MS
First Name:AVA
Middle Name:N
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MS, NCC,LPC
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 4730
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75712-4730
Mailing Address - Country:US
Mailing Address - Phone:903-597-1351
Mailing Address - Fax:903-535-7386
Practice Address - Street 1:2323 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-7704
Practice Address - Country:US
Practice Address - Phone:903-597-1351
Practice Address - Fax:903-535-7386
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19952101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181244801Medicaid