Basic Information
| Provider Information | |||||||||
| NPI: | 1508928680 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | SHANNON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 ASHLEY RD | ||||||||
| Address2: | |||||||||
| City: | APEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275399353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193278730 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2000 YONKERS RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276042258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198967536 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 12/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 3471 | NC | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 3471 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 142CE | 01 | NC | BCBS | OTHER | 6102622 | 05 | NC | MEDICAID |