Provider Demographics
NPI:1154351013
Name:WEAVER, KELLI NICOLE (ASW)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:NICOLE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7001 EAST PKWY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2501
Mailing Address - Country:US
Mailing Address - Phone:916-876-7107
Mailing Address - Fax:
Practice Address - Street 1:7001 EAST PKWY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2501
Practice Address - Country:US
Practice Address - Phone:916-876-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical