Provider Demographics
NPI:1770618407
Name:WEAVER, TAMARA LYN (LCSW)
Entity type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:LYN
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 BAILEY AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:NEEDLES
Mailing Address - State:CA
Mailing Address - Zip Code:92363-3105
Mailing Address - Country:US
Mailing Address - Phone:760-326-9272
Mailing Address - Fax:760-326-9259
Practice Address - Street 1:1600 BAILEY AVE STE 2
Practice Address - Street 2:
Practice Address - City:NEEDLES
Practice Address - State:CA
Practice Address - Zip Code:92363-3105
Practice Address - Country:US
Practice Address - Phone:760-326-9272
Practice Address - Fax:760-326-9259
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA253421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical