Provider Demographics
NPI:1255819413
Name:WEAVER, SAM (LCDC)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:WEAVER
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 MICHIGAN AVE STE F
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-5952
Mailing Address - Country:US
Mailing Address - Phone:817-723-1210
Mailing Address - Fax:
Practice Address - Street 1:2214 MICHIGAN AVE STE F
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-5952
Practice Address - Country:US
Practice Address - Phone:817-723-1210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)