Provider Demographics
NPI:1346331956
Name:BEAVAN, ELISABETH (OTR)
Entity Type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:
Last Name:BEAVAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 TUCKERS LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-3044
Mailing Address - Country:US
Mailing Address - Phone:631-765-2283
Mailing Address - Fax:631-765-6879
Practice Address - Street 1:600 TUCKERS LN
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-3044
Practice Address - Country:US
Practice Address - Phone:631-765-2283
Practice Address - Fax:631-765-6879
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002548-1225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ69371Medicare UPIN
NYQ69373Medicare UPIN
NYQ69372Medicare UPIN