Provider Demographics
NPI:1093811606
Name:BEVILL-DADA, GAYLE
Entity Type:Individual
Prefix:MRS
First Name:GAYLE
Middle Name:
Last Name:BEVILL-DADA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:GAYLE
Other - Middle Name:
Other - Last Name:BEVILL-DADA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:125 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-2429
Mailing Address - Country:US
Mailing Address - Phone:260-456-4801
Mailing Address - Fax:
Practice Address - Street 1:3514 STELLHORN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4631
Practice Address - Country:US
Practice Address - Phone:260-492-5500
Practice Address - Fax:260-422-1555
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001423A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health