Provider Demographics
NPI:1871207530
Name:WEZA, BRIAN (MA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WEZA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 N KEDZIE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-2423
Mailing Address - Country:US
Mailing Address - Phone:360-463-6452
Mailing Address - Fax:
Practice Address - Street 1:3234 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2594
Practice Address - Country:US
Practice Address - Phone:773-466-9882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health