Provider Demographics
NPI:1255393401
Name:WEAVER, THERESA M (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:M
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S WENONA ST
Mailing Address - Street 2:DEPT-TOTAL FAMILY HEALTH CARE STE 170
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-8820
Mailing Address - Country:US
Mailing Address - Phone:989-893-6162
Mailing Address - Fax:
Practice Address - Street 1:200 S WENONA ST
Practice Address - Street 2:DEPT-TOTAL FAMILY HEALTH CARE STE 170
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-8820
Practice Address - Country:US
Practice Address - Phone:989-893-6162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401004225101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12443729OtherCAQH