Healthcare Provider Details

I. General information

NPI: 1326359811
Provider Name (Legal Business Name): BEVERLY JEAN ROBERTS MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4304
US

IV. Provider business mailing address

4296 W MARRISON RD
PENTWATER MI
49449-9630
US

V. Phone/Fax

Practice location:
  • Phone: 616-356-6245
  • Fax:
Mailing address:
  • Phone: 727-422-2183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH10149
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: