Provider Demographics
NPI:1164724522
Name:ABBOTT, BEVERLY ANNE
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANNE
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WOODBINE PL
Mailing Address - Street 2:UNIT 775
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-2912
Mailing Address - Country:US
Mailing Address - Phone:903-237-2315
Mailing Address - Fax:903-757-8294
Practice Address - Street 1:107 WOODBINE PL
Practice Address - Street 2:UNIT 775
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-2912
Practice Address - Country:US
Practice Address - Phone:903-237-2315
Practice Address - Fax:903-757-8294
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64367174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist