Provider Demographics
NPI:1043608680
Name:BEVERLY, BRENDA (CADC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3817 LONE PINE DR APT 2
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-8800
Mailing Address - Country:US
Mailing Address - Phone:989-233-1020
Mailing Address - Fax:
Practice Address - Street 1:1190 WEST
Practice Address - Street 2:1190 WEST SUITE 812
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202
Practice Address - Country:US
Practice Address - Phone:517-513-3657
Practice Address - Fax:517-513-3693
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-00945101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)