Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | P0000002474 | TN |
N | 103G00000X | Clinical Psychologist | P0000002474 | TN |
N | 103TC0700X | Clinical Psychologist | P0000002474 | TN |
NPI | 1154355717 |
---|---|
Provider Name | Dr. Kendra Renee Weaver |
First Address | Gray, TN 37615-3856 |
Second Address | Mountain Home, TN 37684 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2006 |
Last Update Date | 08/07/2007 |