Provider Demographics
NPI:1578885844
Name:WEAVER, MARIANNE A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:A
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S 20TH ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-3538
Mailing Address - Country:US
Mailing Address - Phone:541-663-9350
Mailing Address - Fax:
Practice Address - Street 1:410 S 20TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3538
Practice Address - Country:US
Practice Address - Phone:541-663-9350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1524103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical