Basic Information
| Provider Information | |||||||||
| NPI: | 1790925386 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THEODORE J WEBER M DIV PSYD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28410 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312218410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784751299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 348 CHELSEA PLACE AVE | ||||||||
| Address2: | |||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321740683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784751299 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2009 | ||||||||
| LastUpdateDate: | 02/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | WEBER | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PSYD | ||||||||
| AuthorizedOfficialTelephone: | 4784751299 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY6429 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.