Provider Demographics
NPI:1013553163
Name:BEAVERS, MIRISSA JOY
Entity Type:Individual
Prefix:
First Name:MIRISSA
Middle Name:JOY
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 10TH ST STE 211
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-3156
Mailing Address - Country:US
Mailing Address - Phone:580-256-8615
Mailing Address - Fax:
Practice Address - Street 1:193461 E. COUNTY RD. 304
Practice Address - Street 2:
Practice Address - City:FORT SUPPLY
Practice Address - State:OK
Practice Address - Zip Code:73841
Practice Address - Country:US
Practice Address - Phone:580-766-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker