Provider Demographics
NPI:1215210646
Name:BEVERLY, ROSELLA
Entity Type:Individual
Prefix:MS
First Name:ROSELLA
Middle Name:
Last Name:BEVERLY
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 1:6330 MCLEOD DR. STE#3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-4431
Mailing Address - Country:US
Mailing Address - Phone:702-754-3484
Mailing Address - Fax:702-629-7952
Practice Address - Street 1:6330 MCLEOD DR STE 3
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-4431
Practice Address - Country:US
Practice Address - Phone:702-754-3484
Practice Address - Fax:702-629-7952
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV271538272Medicaid