Provider Demographics
NPI:1376003343
Name:BERVOETS, CARLY MARIE
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:MARIE
Last Name:BERVOETS
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 1:606 GRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-3604
Mailing Address - Country:US
Mailing Address - Phone:615-474-2274
Mailing Address - Fax:
Practice Address - Street 1:2007 OLD LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3510
Practice Address - Country:US
Practice Address - Phone:706-861-9390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)