Provider Demographics
NPI:1326359811
Name:ROBERTS, BEVERLY JEAN (MA)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JEAN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4296 W MARRISON RD
Mailing Address - Street 2:
Mailing Address - City:PENTWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49449-9630
Mailing Address - Country:US
Mailing Address - Phone:727-422-2183
Mailing Address - Fax:
Practice Address - Street 1:40 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4304
Practice Address - Country:US
Practice Address - Phone:616-356-6245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10149101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health