Provider Demographics
NPI:1821159294
Name:WEYANT, KELLY J (CADC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:WEYANT
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:IA
Mailing Address - Zip Code:50644-3145
Mailing Address - Country:US
Mailing Address - Phone:319-334-3371
Mailing Address - Fax:319-334-3781
Practice Address - Street 1:309 1ST ST E
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:IA
Practice Address - Zip Code:50644-2854
Practice Address - Country:US
Practice Address - Phone:319-334-3547
Practice Address - Fax:319-334-3781
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1260101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)