Provider Demographics
NPI:1073508743
Name:BEVERSDORF, JAMES R (LAT, CSCS, PES)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:BEVERSDORF
Suffix:
Gender:M
Credentials:LAT, CSCS, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 PACKERLAND DR
Mailing Address - Street 2:APT. B-3
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-1388
Mailing Address - Country:US
Mailing Address - Phone:920-405-0872
Mailing Address - Fax:
Practice Address - Street 1:215 N WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4813
Practice Address - Country:US
Practice Address - Phone:920-430-4750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer