Healthcare Provider Details

I. General information

NPI: 1497586705
Provider Name (Legal Business Name): JUANITA BEVERLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 08/15/2026
Certification Date: 08/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

292 EUCLID AVE STE 225
SAN DIEGO CA
92114-3629
US

IV. Provider business mailing address

292 EUCLID AVE STE 225
SAN DIEGO CA
92114-3629
US

V. Phone/Fax

Practice location:
  • Phone: 858-325-8417
  • Fax: 858-325-8417
Mailing address:
  • Phone: 858-325-8417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-MBQXZL
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: