Provider Demographics
NPI:1750604203
Name:WEAVER, MARY KATHERINE (LMSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 BEAUBIEN ST
Mailing Address - Street 2:CRISIS CENTER
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2119
Mailing Address - Country:US
Mailing Address - Phone:313-966-6833
Mailing Address - Fax:313-745-4879
Practice Address - Street 1:3901 BEAUBIEN ST
Practice Address - Street 2:CRISIS CENTER
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-966-6833
Practice Address - Fax:313-745-4879
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801083404104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker