Provider Demographics
NPI:1104371046
Name:WEAVER, AMANDA (LCPC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4602 SCHENLEY RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-2526
Mailing Address - Country:US
Mailing Address - Phone:410-205-9782
Mailing Address - Fax:
Practice Address - Street 1:10 W MADISON ST
Practice Address - Street 2:#11
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5239
Practice Address - Country:US
Practice Address - Phone:443-438-7863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-21
Last Update Date:2016-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7221101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional