MEDICARE: DR. KENNETH ALLEN BEAVERS PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	4271	OH

General Provider Information

NPI Number	:	1124005400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH ALLEN BEAVERS PHD

Provider Business Mailing Address
First Line	:	1115 BETHEL RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43220-2690
Country	:	US
Telephone Number	:	614-459-3003
Fax Number	:	614-451-3017

Provider Business Practice Location Address
First Line	:	1115 BETHEL RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43220-2690
Country	:	US
Telephone Number	:	614-459-3003
Fax Number	:	614-451-3017

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	07/08/2007

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