Provider Demographics
NPI:1447770334
Name:WEAVER, MELISSA KAITLYN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:KAITLYN
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 PALM DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-3316
Mailing Address - Country:US
Mailing Address - Phone:407-591-0695
Mailing Address - Fax:
Practice Address - Street 1:2050 CLASSIQUE LN
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5787
Practice Address - Country:US
Practice Address - Phone:352-508-5243
Practice Address - Fax:352-602-4142
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician