Healthcare Provider Details

I. General information

NPI: 1295910065
Provider Name (Legal Business Name): BEVERLY MICHAEL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2007
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 MESA BLVD SUITE D
GRANTS NM
87020-3038
US

IV. Provider business mailing address

1109 MESA BLVD SUITE D
GRANTS NM
87020-3038
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-3773
  • Fax: 505-287-5115
Mailing address:
  • Phone: 505-287-3773
  • Fax: 505-287-5115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number03-074959-00-0
License Number StateNM

VIII. Authorized Official

Name: BEVERLY MICHAEL
Title or Position: OWNER/OPERATOR
Credential: LISW
Phone: 505-287-3773