Provider Demographics
NPI:1568965903
Name:WEAVER, ANDREA JILL (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:JILL
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 TRIBUTE CENTER DR APT 306
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1206 W CHATHAM ST
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-5246
Practice Address - Country:US
Practice Address - Phone:919-461-0253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11260225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist