1598942435 NPI number — PATRICIA A BEVERLY M.A.CCC-SP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598942435 NPI number — PATRICIA A BEVERLY M.A.CCC-SP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEVERLY
Provider First Name:
PATRICIA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.CCC-SP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598942435
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 49663
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28277-0082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-845-6134
Provider Business Mailing Address Fax Number:
704-845-8024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 SARDIS RD N
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28227-7711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-845-6134
Provider Business Practice Location Address Fax Number:
704-845-8024
Provider Enumeration Date:
01/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7415325 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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