Healthcare Provider Details

I. General information

NPI: 1023832375
Provider Name (Legal Business Name): MARK BEVERLY PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 617
SOMERTON AZ
85350-0617
US

IV. Provider business mailing address

11417 W PICCADILLY RD
AVONDALE AZ
85392-3428
US

V. Phone/Fax

Practice location:
  • Phone: 928-315-7910
  • Fax: 928-722-6113
Mailing address:
  • Phone: 805-200-9336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number94028875
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number94028875
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-T-000071
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: