Provider Demographics
NPI:1194211409
Name:BEVERLY, TIMOTHY RAY (CDCA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:RAY
Last Name:BEVERLY
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CROWNE POINT PLACE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-5427
Mailing Address - Country:US
Mailing Address - Phone:513-743-7628
Mailing Address - Fax:
Practice Address - Street 1:302 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5037
Practice Address - Country:US
Practice Address - Phone:937-281-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH070488101YA0400X
OHLCDCII.161829101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)