Provider Demographics
NPI:1780620153
Name:WEAVER, RENETTA DIANE (LICSW & LCSW-C)
Entity type:Individual
Prefix:MRS
First Name:RENETTA
Middle Name:DIANE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LICSW & LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2893 CAMEO PL
Mailing Address - Street 2:
Mailing Address - City:BRYANS ROAD
Mailing Address - State:MD
Mailing Address - Zip Code:20616-7010
Mailing Address - Country:US
Mailing Address - Phone:301-455-5032
Mailing Address - Fax:
Practice Address - Street 1:2893 CAMEO PL
Practice Address - Street 2:
Practice Address - City:BRYANS ROAD
Practice Address - State:MD
Practice Address - Zip Code:20616-7010
Practice Address - Country:US
Practice Address - Phone:301-455-5032
Practice Address - Fax:301-455-5032
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500781771041C0700X
101YA0400X
MD199321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)