Provider Demographics
NPI:1063594034
Name:WEAVER, KELLY JEAN (MED, EDS, LPC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEAN
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MED, EDS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-3546
Mailing Address - Country:US
Mailing Address - Phone:803-808-5222
Mailing Address - Fax:803-957-2042
Practice Address - Street 1:224 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-3546
Practice Address - Country:US
Practice Address - Phone:803-808-5222
Practice Address - Fax:803-957-2042
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2760101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional