Provider Demographics
NPI:1174184881
Name:BEAVERS, MITCHELL GLEN (PHD, PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:GLEN
Last Name:BEAVERS
Suffix:
Gender:M
Credentials:PHD, PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 HELEN KELLER BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-2963
Mailing Address - Country:US
Mailing Address - Phone:205-344-6169
Mailing Address - Fax:
Practice Address - Street 1:661 HELEN KELLER BLVD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-2963
Practice Address - Country:US
Practice Address - Phone:205-344-6169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2103103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist