MEDICARE: KELLY BEVERLY

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	101YS0200X	School Counselor

General Provider Information

NPI Number	:	1861073223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY BEVERLY

Provider Business Mailing Address
First Line	:	7679 COURTNEY OAKS DR APT 2088
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-4628
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7679 COURTNEY OAKS DR APT 2088
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-4628
Country	:	US
Telephone Number	:	682-287-4353
Fax Number	:

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

Provider Enumeration Date	:	04/17/2021
Last Update Date	:	04/17/2021

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Directions to “ KELLY BEVERLY ” Practice Location

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