Provider Demographics
NPI:1629487111
Name:WEAVER, CHARLES COULTER III (LPC, LMFT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:COULTER
Last Name:WEAVER
Suffix:III
Gender:M
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5616I OX RD UNIT 194
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039-8014
Mailing Address - Country:US
Mailing Address - Phone:703-475-2221
Mailing Address - Fax:703-684-3407
Practice Address - Street 1:2924 KING ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-3512
Practice Address - Country:US
Practice Address - Phone:703-475-2221
Practice Address - Fax:703-684-3407
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001741101YP2500X
VA0717000869106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional