Provider Demographics
NPI:1972664464
Name:WEISS, DAVID CHARLES (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CHARLES
Last Name:WEISS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 MERRIMAC PL
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-1624
Mailing Address - Country:US
Mailing Address - Phone:207-799-7054
Mailing Address - Fax:207-767-7380
Practice Address - Street 1:345 COTTAGE RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3919
Practice Address - Country:US
Practice Address - Phone:207-799-9595
Practice Address - Fax:
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
MEMF1830106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME41Z047229ME01OtherANTHEM BCBS