Provider Demographics
NPI:1821595554
Name:WEBER, KATHERINE MARY (MA)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:MARY
Last Name:WEBER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5218 CAMERON CREEK CIR APT 258
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3213
Mailing Address - Country:US
Mailing Address - Phone:845-926-6322
Mailing Address - Fax:
Practice Address - Street 1:1617 HEMPHILL ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4709
Practice Address - Country:US
Practice Address - Phone:817-702-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38172103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program