Provider Demographics
NPI:1457787038
Name:WEAVER, ROBERT KYLE (LCDC-3)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:KYLE
Last Name:WEAVER
Suffix:
Gender:M
Credentials:LCDC-3
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 GREENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-3033
Mailing Address - Country:US
Mailing Address - Phone:937-746-1154
Mailing Address - Fax:937-746-8523
Practice Address - Street 1:975 KINGSVIEW DR
Practice Address - Street 2:SUITE 400
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-9562
Practice Address - Country:US
Practice Address - Phone:513-228-7854
Practice Address - Fax:513-228-7848
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDC-131200-3101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)