Provider Demographics
NPI:1184984791
Name:WEAVER, LYNETTE ARLENE (P-LCAS)
Entity type:Individual
Prefix:MS
First Name:LYNETTE
Middle Name:ARLENE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:P-LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 ROSEMONT DR
Mailing Address - Street 2:#25
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-7923
Mailing Address - Country:US
Mailing Address - Phone:252-378-6417
Mailing Address - Fax:
Practice Address - Street 1:2317 EXECUTIVE CIR STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3762
Practice Address - Country:US
Practice Address - Phone:252-353-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health