Provider Demographics
NPI:1871586222
Name:WEYAND, MICHAEL CHARLES (MSW, LICSW, LCSW,)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:WEYAND
Suffix:
Gender:M
Credentials:MSW, LICSW, LCSW,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E 4TH PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-3753
Mailing Address - Country:US
Mailing Address - Phone:360-624-2744
Mailing Address - Fax:
Practice Address - Street 1:108 SE 124TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6015
Practice Address - Country:US
Practice Address - Phone:360-891-7421
Practice Address - Fax:360-253-8358
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00004960101YA0400X
OR03-R-04101YA0400X
MI2-00645101YA0400X
WALW000078841041C0700X
ORL33861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1871586222Medicaid
WA1871586222Medicaid