Healthcare Provider Details

I. General information

NPI: 1720564123
Provider Name (Legal Business Name): SARA NICOLE BEVERLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 INNOVATION DR STE 2000
GREENVILLE SC
29607-5253
US

IV. Provider business mailing address

10 PEARL ST FL 2
PORT CHESTER NY
10573-4611
US

V. Phone/Fax

Practice location:
  • Phone: 864-603-6300
  • Fax: 877-379-2919
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15387
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number093453
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number103867
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: