Provider Demographics
NPI:1316700206
Name:WEATHERS, JOHNATHON
Entity type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:
Last Name:WEATHERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 WILLARD ST UNIT 404
Mailing Address - Street 2:APT 404
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-981-5525
Mailing Address - Fax:
Practice Address - Street 1:445 WILLARD ST UNIT 404
Practice Address - Street 2:APT 404
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-981-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor