Provider Demographics
NPI:1013767243
Name:WEAVER, SHAWNDA (MMT)
Entity type:Individual
Prefix:
First Name:SHAWNDA
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4502
Mailing Address - Country:US
Mailing Address - Phone:870-335-0625
Mailing Address - Fax:
Practice Address - Street 1:110 W COURT ST
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4336
Practice Address - Country:US
Practice Address - Phone:870-335-0625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8023225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist