Provider Demographics
NPI:1699791541
Name:WEIS, KEVIN JAMES (PSYD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAMES
Last Name:WEIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 BROOKSTONE CENTRE PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-4500
Mailing Address - Country:US
Mailing Address - Phone:706-653-6841
Mailing Address - Fax:706-653-7843
Practice Address - Street 1:2325 BROOKSTONE CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-4500
Practice Address - Country:US
Practice Address - Phone:706-653-6841
Practice Address - Fax:706-653-7843
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003142103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54641OtherBLUECROSSBLUESHIELD
FL7761336OtherAETNA PROVIDER NUMBER