Provider Demographics
NPI:1740857705
Name:WEATHINGTON, CALVIN JR
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:WEATHINGTON
Suffix:JR
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 1:2530 BERRYESSA RD APT 452
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-2903
Mailing Address - Country:US
Mailing Address - Phone:408-561-4322
Mailing Address - Fax:
Practice Address - Street 1:1885 LUNDY AVE STE 223
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-1888
Practice Address - Country:US
Practice Address - Phone:408-284-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional