Provider Demographics
NPI:1326446840
Name:MUSTAINE, BEVERLY
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:
Last Name:MUSTAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:LYNNE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDD, LMHC,CCMHC
Mailing Address - Street 1:2019 HOPKINS DR W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-4736
Mailing Address - Country:US
Mailing Address - Phone:941-755-1795
Mailing Address - Fax:
Practice Address - Street 1:2019 HOPKINS DR W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-4736
Practice Address - Country:US
Practice Address - Phone:941-755-1795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10950101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health