Provider Demographics
NPI:1356505978
Name:BEVERLY, DIANE (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1967 S OCEAN BLVD
Mailing Address - Street 2:311
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-8014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-3542
Practice Address - Country:US
Practice Address - Phone:954-942-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-13
Last Update Date:2008-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0010442225100000X
NY003452225100000X
CT2481225100000X
WA60003825225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist