Provider Demographics
NPI:1033483276
Name:BEVERLY GARDNER LLC
Entity Type:Organization
Organization Name:BEVERLY GARDNER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:719-660-5281
Mailing Address - Street 1:10 BOULDER CRESCENT ST
Mailing Address - Street 2:SUITE 203F
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3344
Mailing Address - Country:US
Mailing Address - Phone:719-660-5281
Mailing Address - Fax:866-703-1432
Practice Address - Street 1:10 BOULDER CRESCENT ST
Practice Address - Street 2:SUITE 203F
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3344
Practice Address - Country:US
Practice Address - Phone:719-660-5281
Practice Address - Fax:866-703-1432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1820251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health