Doctor Name: | BEVERLY MICHAEL |
NPI Number: | 1336263656 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | LISW |
License Number: | I-06355 |
Business Practice Address: | 1109 Mesa Blvd Suite D Grants, NM - 870203038 |
Business Phone Number: | 5059800886 |
Business Fax Number: | |
Mailing Address: | 1109 Mesa Blvd, Suite D GRANTS |
State: | NM |
Postal Code: | 870203038 |
Phone Number: | 5059800886 |
Fax Number: | |
NPI Enumeration Date: | 03/19/2007 |
NPI Last Update Date: | 11/17/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | I-06355 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NM |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |