Provider Demographics
NPI:1639219504
Name:WEAVER, ELIZABETH LAUREN (MSP, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:LAUREN
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9614 BLACK WATCH CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2139
Mailing Address - Country:US
Mailing Address - Phone:704-575-6079
Mailing Address - Fax:704-341-9906
Practice Address - Street 1:9614 BLACK WATCH CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2139
Practice Address - Country:US
Practice Address - Phone:704-575-6079
Practice Address - Fax:704-341-9906
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6188235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412183Medicaid