MEDICARE: MS. BEVERLY ANN GARDNER-NELSON LMSW-AP, LCDC, CCJP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	S06143	TX
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	5737	TX
3	104100000X	Social Worker	S06143	TX
4	251B00000X	Case Management Agency	06143	TX

General Provider Information

NPI Number	:	1093865065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BEVERLY ANN GARDNER-NELSON LMSW-AP, LCDC, CCJP

Provider Business Mailing Address
First Line	:	11717 BEAMER RD
Second Line	:	APT. 245
City	:	HOUSTON
State	:	TX
Zip	:	77089-3100
Country	:	US
Telephone Number	:	281-481-1774
Fax Number	:	281-464-8683

Provider Business Practice Location Address
First Line	:	9000 FREY RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77034-3506
Country	:	US
Telephone Number	:	713-851-5302
Fax Number	:	281-464-8683

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	09/09/2015

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