Healthcare Provider Details

I. General information

NPI: 1124005400
Provider Name (Legal Business Name): KENNETH ALLEN BEAVERS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BETHEL RD
COLUMBUS OH
43220-2690
US

IV. Provider business mailing address

1115 BETHEL RD
COLUMBUS OH
43220-2690
US

V. Phone/Fax

Practice location:
  • Phone: 614-459-3003
  • Fax: 614-451-3017
Mailing address:
  • Phone: 614-459-3003
  • Fax: 614-451-3017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4271
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: