1053618587 NPI number — MRS. ESTELLE DELORES WEAVER LBSW

Table of content: MRS. ESTELLE DELORES WEAVER LBSW (NPI 1053618587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053618587 NPI number — MRS. ESTELLE DELORES WEAVER LBSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEAVER
Provider First Name:
ESTELLE
Provider Middle Name:
DELORES
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LBSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SPENCER
Provider Other First Name:
ESTELLE
Provider Other Middle Name:
DELORES
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LBSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053618587
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13101 ALLEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHGATE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48195-2216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-785-7700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13101 ALLEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHGATE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48195-2216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-785-7700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6802080949 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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