Provider Demographics
NPI:1639553852
Name:WEISNER, MATTHEW BENJAMIN (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BENJAMIN
Last Name:WEISNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1
Mailing Address - Street 2:
Mailing Address - City:BARIUM SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28010-0001
Mailing Address - Country:US
Mailing Address - Phone:704-873-1011
Mailing Address - Fax:704-832-2253
Practice Address - Street 1:5700 EXECUTIVE CENTER DR
Practice Address - Street 2:STE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8858
Practice Address - Country:US
Practice Address - Phone:704-330-4338
Practice Address - Fax:704-330-5265
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0094151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical