Provider Demographics
NPI:1972379311
Name:WEAVER, TYRONE JARVIS SR (MS)
Entity Type:Individual
Prefix:MR
First Name:TYRONE
Middle Name:JARVIS
Last Name:WEAVER
Suffix:SR
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3929 BROUGHTON CT
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-3722
Mailing Address - Country:US
Mailing Address - Phone:916-501-2794
Mailing Address - Fax:
Practice Address - Street 1:2617 K ST STE 125
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5133
Practice Address - Country:US
Practice Address - Phone:916-633-0854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT133817106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist