Provider Demographics
NPI:1053052597
Name:BEVIL, MARY ANNE (LCDC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANNE
Last Name:BEVIL
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4673 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-4330
Mailing Address - Country:US
Mailing Address - Phone:409-840-9350
Mailing Address - Fax:409-840-9366
Practice Address - Street 1:4673 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-4330
Practice Address - Country:US
Practice Address - Phone:409-840-9350
Practice Address - Fax:409-840-9366
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15350101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)