Provider Demographics
NPI:1518484740
Name:WESTON, GEORGIA ROXANNE
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:ROXANNE
Last Name:WESTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GEORGIA
Other - Middle Name:ROXANNE
Other - Last Name:HUSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:613 HAMPSHIRE RD APT 485
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-2325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4900 SERRANIA AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364
Practice Address - Country:US
Practice Address - Phone:818-347-1577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 390200000X
CA83245101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program