Provider Demographics
NPI:1790925386
Name:THEODORE J WEBER M DIV PSYD PA
Entity Type:Organization
Organization Name:THEODORE J WEBER M DIV PSYD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYD
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-475-1299
Mailing Address - Street 1:PO BOX 28410
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-8410
Mailing Address - Country:US
Mailing Address - Phone:478-475-1299
Mailing Address - Fax:
Practice Address - Street 1:348 CHELSEA PLACE AVE
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-0683
Practice Address - Country:US
Practice Address - Phone:478-475-1299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6429103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54774Medicare PIN