Provider Demographics
NPI:1366417412
Name:WEATHERSTON, MARY (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WEATHERSTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 S ADAMS RD
Mailing Address - Street 2:STE 244
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6902
Mailing Address - Country:US
Mailing Address - Phone:248-642-2411
Mailing Address - Fax:
Practice Address - Street 1:725 S ADAMS RD
Practice Address - Street 2:STE 244
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6902
Practice Address - Country:US
Practice Address - Phone:248-642-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008672103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M67710Medicare PIN