Provider Demographics
NPI:1699743203
Name:WEISSMAN, MICHAEL S (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:WEISSMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 BOTETOURT GDNS
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-2203
Mailing Address - Country:US
Mailing Address - Phone:757-483-3404
Mailing Address - Fax:
Practice Address - Street 1:3210 CHURCHLAND BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5253
Practice Address - Country:US
Practice Address - Phone:757-483-3404
Practice Address - Fax:757-483-0461
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810-000761103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA028681OtherANTHEM
VAN0007781342Medicaid