Provider Demographics
NPI:1194218602
Name:SMITH, BEVERLY ROSE
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:ROSE
Other - Last Name:PRAUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:310 N INDIAN HILL BLVD STE 533
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4611
Mailing Address - Country:US
Mailing Address - Phone:909-964-2897
Mailing Address - Fax:
Practice Address - Street 1:219 N INDIAN HILL BLVD STE 103
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4644
Practice Address - Country:US
Practice Address - Phone:909-964-2897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP7534235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist