Provider Demographics
NPI:1215034467
Name:WINTER, BEVERLY YVONNE (EDS)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:YVONNE
Last Name:WINTER
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 CIRCLE ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3212
Mailing Address - Country:US
Mailing Address - Phone:304-253-4641
Mailing Address - Fax:
Practice Address - Street 1:304 CIRCLE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3212
Practice Address - Country:US
Practice Address - Phone:304-253-4641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV487101YP2500X
WV21016103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0165893000Medicaid