Healthcare Provider Details

I. General information

NPI: 1720209307
Provider Name (Legal Business Name): BEVERLEE J GIBBS-CASSADY ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 N KENDRICK ST STE 3
FLAGSTAFF AZ
86001-1598
US

IV. Provider business mailing address

416 N KENDRICK ST STE 3
FLAGSTAFF AZ
86001-1598
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-7778
  • Fax: 928-913-0891
Mailing address:
  • Phone: 928-774-7778
  • Fax: 928-913-0891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3410
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3410
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3410
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: