Provider Demographics
NPI:1871786558
Name:WEAVER, MARINEL (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARINEL
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:MARYNELLE
Other - Middle Name:
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:4700 SPRING ST
Mailing Address - Street 2:SUITE # 204
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-5263
Mailing Address - Country:US
Mailing Address - Phone:619-465-4357
Mailing Address - Fax:619-312-2098
Practice Address - Street 1:4700 SPRING ST
Practice Address - Street 2:SUITE # 204
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5263
Practice Address - Country:US
Practice Address - Phone:619-465-4357
Practice Address - Fax:619-312-2098
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 156271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS 15627OtherBOARD OF BEHAVIORAL SCIEN
SW15627AMedicare PIN