MEDICARE: ROCKLAN BEAVERS M.A.

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	101YM0800X	Mental Health Counselor	8408	TN

General Provider Information

NPI Number	:	1255135711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROCKLAN BEAVERS M.A.

Provider Business Mailing Address
First Line	:	5842 HIGHWAY 30
Second Line	:
City	:	BENTON
State	:	TN
Zip	:	37307-4734
Country	:	US
Telephone Number	:	406-206-9255
Fax Number	:

Provider Business Practice Location Address
First Line	:	5840 TN-30
Second Line	:
City	:	BENTON
State	:	TN
Zip	:	37307
Country	:	US
Telephone Number	:	706-573-4110
Fax Number	:

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

Provider Enumeration Date	:	04/03/2025
Last Update Date	:	06/05/2026

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Directions to “ ROCKLAN BEAVERS M.A.” Practice Location

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