Basic Information
| Provider Information | |||||||||
| NPI: | 1124430442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BACHELORS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 BAKER PINE RD | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028981000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017248400 | ||||||||
| FaxNumber: | 4017225280 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 BAKER PINE RD | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028981000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017248400 | ||||||||
| FaxNumber: | 4017225280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2014 | ||||||||
| LastUpdateDate: | 05/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | GH57134 | 05 | RI | MEDICAID |