Provider Demographics
NPI:1780396531
Name:WEAVER, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 SANTA FE ST APT 47
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-3439
Mailing Address - Country:US
Mailing Address - Phone:512-796-7350
Mailing Address - Fax:
Practice Address - Street 1:3501 SHEPPARD ACCESS RD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76306-4235
Practice Address - Country:US
Practice Address - Phone:940-386-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX828883106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX828883OtherBCBA