Healthcare Provider Details

I. General information

NPI: 1205940509
Provider Name (Legal Business Name): BEVERLY KNIGHTEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEDOM WAY
AUGUSTA GA
30904-6258
US

IV. Provider business mailing address

3101 ELK DR
MCALESTER OK
74501-7606
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax:
Mailing address:
  • Phone: 229-584-2540
  • Fax: 229-226-2036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4950
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW005914
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7117
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2283-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: