=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487151551
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEVERLEY DIANE GRAY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2018
-----------------------------------------------------
Last Update Date | 03/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5509 W FRIENDLY AVE STE B
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27410-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-617-3152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 COLLINGTON DR
-----------------------------------------------------
City | MEBANE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27302-8683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-599-7751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | A13734
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 13734
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------