MEDICARE: KISHA BEVERLY

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	104100000X	Social Worker	MI
2	251B00000X	Case Management Agency	MI
3	171400000X	Health & Wellness Coach	MI
4	172V00000X	Community Health Worker	MI
5	171M00000X	Case Manager/Care Coordinator	MI
6	101YM0800X	Mental Health Counselor	MI

General Provider Information

NPI Number	:	1790624682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KISHA BEVERLY

Provider Business Mailing Address
First Line	:	5303 S CEDAR ST STE 3
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48911-3800
Country	:	US
Telephone Number	:	517-231-2482
Fax Number	:

Provider Business Practice Location Address
First Line	:	5303 S CEDAR ST STE 3
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48911-3800
Country	:	US
Telephone Number	:	517-231-2482
Fax Number	:

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

Provider Enumeration Date	:	03/26/2026
Last Update Date	:	03/26/2026

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Directions to “ KISHA BEVERLY ” Practice Location

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