Provider Demographics
NPI:1710250634
Name:WEAVER, CELENA C (BHRS)
Entity Type:Individual
Prefix:
First Name:CELENA
Middle Name:C
Last Name:WEAVER
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 CARRIAGE POING RD
Mailing Address - Street 2:
Mailing Address - City:CALERA
Mailing Address - State:OK
Mailing Address - Zip Code:74730
Mailing Address - Country:US
Mailing Address - Phone:580-465-8740
Mailing Address - Fax:
Practice Address - Street 1:715 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3801
Practice Address - Country:US
Practice Address - Phone:580-931-3008
Practice Address - Fax:580-931-8022
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040FMedicaid