MEDICARE: BEVIN NICOLE DEMUTH LCSW

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	1041C0700X	Clinical Social Worker	LCSW75553	CA
2	101YM0800X	Mental Health Counselor	LCSW75553	CA

General Provider Information

NPI Number	:	1437565280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVIN NICOLE DEMUTH LCSW

Provider Business Mailing Address
First Line	:	2028 PARK ROYAL DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-4648
Country	:	US
Telephone Number	:	650-305-1044
Fax Number	:

Provider Business Practice Location Address
First Line	:	2028 PARK ROYAL DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-4648
Country	:	US
Telephone Number	:	650-305-1044
Fax Number	:

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

Provider Enumeration Date	:	07/01/2014
Last Update Date	:	01/19/2021

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