Provider Demographics
NPI:1548684715
Name:WEAVER, RICHARD CARLTON (MA, LPC, NCC, CBIS,)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:CARLTON
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MA, LPC, NCC, CBIS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 W MAPLE RD STE D401
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3711
Mailing Address - Country:US
Mailing Address - Phone:248-881-0944
Mailing Address - Fax:248-851-7607
Practice Address - Street 1:5600 W MAPLE RD STE D401
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3711
Practice Address - Country:US
Practice Address - Phone:248-881-0944
Practice Address - Fax:248-851-7607
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-09
Last Update Date:2014-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012674101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional