MEDICARE: MRS. SHAVONDA LATIEA BEAN MA, LPA

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	2477	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2118431	OTHER	NC	CIGNA
2	E4167-B0775	OTHER	NC	MEDCOST
3	046KT	OTHER	NC	BCBS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770573990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHAVONDA LATIEA BEAN MA, LPA

Provider Business Mailing Address
First Line	:	8430 UNIVERSITY EXEC PARK DR
Second Line	:	SUITE 655
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1350
Country	:	US
Telephone Number	:	704-596-5553
Fax Number	:	704-596-1556

Provider Business Practice Location Address
First Line	:	8430 UNIVERSITY EXEC PARK DR
Second Line	:	SUITE 655
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1350
Country	:	US
Telephone Number	:	704-596-5553
Fax Number	:	704-596-1556

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

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	04/25/2013

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