Provider Demographics
NPI:1801360193
Name:WEIGHTMAN, LAURYN
Entity Type:Individual
Prefix:
First Name:LAURYN
Middle Name:
Last Name:WEIGHTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16540 BENT PALMS CV UNIT 7
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-3155
Mailing Address - Country:US
Mailing Address - Phone:239-940-1438
Mailing Address - Fax:
Practice Address - Street 1:2180 MARAVILLA LN STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7221
Practice Address - Country:US
Practice Address - Phone:239-202-8993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16668101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health