Provider Demographics
NPI:1659767960
Name:WEATHERTON, EQUILLA (MS NCC LPC)
Entity Type:Individual
Prefix:
First Name:EQUILLA
Middle Name:
Last Name:WEATHERTON
Suffix:
Gender:F
Credentials:MS NCC LPC
Other - Prefix:
Other - First Name:EQUILLA
Other - Middle Name:
Other - Last Name:GILMORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:109 N MEADOW ST
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-2515
Mailing Address - Country:US
Mailing Address - Phone:726-610-4404
Mailing Address - Fax:726-204-8540
Practice Address - Street 1:109 N MEADOW ST
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109-2515
Practice Address - Country:US
Practice Address - Phone:726-610-4404
Practice Address - Fax:726-204-8540
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70847101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor