Provider Demographics
NPI:1952991754
Name:WEAVER, SAMANTHA DAWN
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:DAWN
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 1:395 SEYMOUR RD
Mailing Address - Street 2:
Mailing Address - City:WEST CHAZY
Mailing Address - State:NY
Mailing Address - Zip Code:12992-2324
Mailing Address - Country:US
Mailing Address - Phone:518-534-0135
Mailing Address - Fax:
Practice Address - Street 1:15 4TH ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1340
Practice Address - Country:US
Practice Address - Phone:518-481-8160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program