Healthcare Provider Details

I. General information

NPI: 1003356791
Provider Name (Legal Business Name): NATHAN BEVENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BRANSCOMB RD
LAYTONVILLE CA
95454
US

IV. Provider business mailing address

4585 SW 185TH AVE
ALOHA OR
97078-1557
US

V. Phone/Fax

Practice location:
  • Phone: 707-984-6131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number75856
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number75856
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number75856
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: