Provider Demographics
NPI:1316975691
Name:WEBER, THEODORE JOSEPH (MDIV, PSYD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:JOSEPH
Last Name:WEBER
Suffix:
Gender:M
Credentials:MDIV, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 CHELSEA PLACE AVE
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-0683
Mailing Address - Country:US
Mailing Address - Phone:386-795-7673
Mailing Address - Fax:386-677-2107
Practice Address - Street 1:348 CHELSEA PLACE AVE
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-0683
Practice Address - Country:US
Practice Address - Phone:386-795-7673
Practice Address - Fax:386-677-2107
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6429103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54774Medicare ID - Type Unspecified