Provider Demographics
NPI:1861762098
Name:WEAVER, RONDA JANETTE (LPC)
Entity type:Individual
Prefix:
First Name:RONDA
Middle Name:JANETTE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 248
Mailing Address - Street 2:
Mailing Address - City:FORT COBB
Mailing Address - State:OK
Mailing Address - Zip Code:73038-9314
Mailing Address - Country:US
Mailing Address - Phone:405-668-0147
Mailing Address - Fax:
Practice Address - Street 1:901 S BROADWAY
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:OK
Practice Address - Zip Code:73651-1834
Practice Address - Country:US
Practice Address - Phone:580-726-3383
Practice Address - Fax:580-726-3384
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4194101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1093897415Medicaid