Provider Demographics
NPI:1730635731
Name:WEAVER, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:WEAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35181 PLEASANT FARM RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:MI
Mailing Address - Zip Code:48062-4235
Mailing Address - Country:US
Mailing Address - Phone:810-305-9649
Mailing Address - Fax:
Practice Address - Street 1:2 CROCKER BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2528
Practice Address - Country:US
Practice Address - Phone:810-305-9649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2023-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801106824104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty