Provider Demographics
NPI:1053878975
Name:WEAVER, KEITH W (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19999 DOTTIE LN
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MO
Mailing Address - Zip Code:64673-8023
Mailing Address - Country:US
Mailing Address - Phone:801-688-8240
Mailing Address - Fax:
Practice Address - Street 1:314 W 1700 S
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-7542
Practice Address - Country:US
Practice Address - Phone:801-610-9313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220137531041C0700X
NY0964671041C0700X
WVTH009462051041C0700X
UT323944-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY096467OtherLCSW NY LICENSING
MO2022013753OtherLICENSED CLINICAL SOCIAL WORKER
WVTH00946205OtherLCSW - WV LICENSING
UT323944-3501OtherSTATE OF UTAH