Healthcare Provider Details

I. General information

NPI: 1639603129
Provider Name (Legal Business Name): MARY BEAVERS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 CLEVELAND HWY
DALTON GA
30721-8160
US

IV. Provider business mailing address

1401 APPLEWOOD DR SUITE 1
DALTON GA
30720-2699
US

V. Phone/Fax

Practice location:
  • Phone: 706-270-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC001997
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: