Basic Information
| Provider Information | |||||||||
| NPI: | 1477969525 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEISE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | MAXWELL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1527 4TH ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904012332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103949871 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1527 4TH ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904012332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103949871 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2014 | ||||||||
| LastUpdateDate: | 07/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.