Provider Demographics
NPI:1689687733
Name:WEAVER, RANDALL PAUL (MSW LCSW 3920)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:PAUL
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MSW LCSW 3920
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 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3696
Practice Address - Street 1:101 LENA DRIVE
Practice Address - Street 2:HAWKINS CN MENTAL HEALTH CTR
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857
Practice Address - Country:US
Practice Address - Phone:423-272-9239
Practice Address - Fax:423-272-1803
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLCSW3920104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
4076033OtherMAGELLAN NAVIGATOR
100884OtherANTHEM PROF TRIGON
4076033OtherMAGELLAN SUMMIT
100884OtherANTHEM PREF TRIGON
178871OtherANTHEM PROF TRIGON HAWKIN
178871OtherANTHEM PREF TRIGON HAWKIN
4076033OtherMAGELLAN PINNACLE
4076033OtherMAGELLAN NAVIGATOR
4076033OtherMAGELLAN PINNACLE