Provider Demographics
NPI:1720618937
Name:WEAVER, BENJAMIN KENNETH
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:KENNETH
Last Name:WEAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 MUNSON ST NW STE A
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2981
Mailing Address - Country:US
Mailing Address - Phone:330-915-2907
Mailing Address - Fax:
Practice Address - Street 1:4522 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2332
Practice Address - Country:US
Practice Address - Phone:330-915-2907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-16
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2304963101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional