Provider Demographics
NPI:1720320690
Name:JAMES WEAVER PSYCHOLOGICAL SERVICES PC
Entity Type:Organization
Organization Name:JAMES WEAVER PSYCHOLOGICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-239-9357
Mailing Address - Street 1:38 ENLOE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10537-1201
Mailing Address - Country:US
Mailing Address - Phone:646-239-9357
Mailing Address - Fax:
Practice Address - Street 1:1994 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOHEGAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:10547-1231
Practice Address - Country:US
Practice Address - Phone:646-239-9357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014825103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02696308Medicaid