Provider Demographics
NPI:1427208164
Name:BEVERAGE, MARY E (LIC AC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:BEVERAGE
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6256 VT ROUTE 30
Mailing Address - Street 2:
Mailing Address - City:PAWLET
Mailing Address - State:VT
Mailing Address - Zip Code:05761-9603
Mailing Address - Country:US
Mailing Address - Phone:802-325-3300
Mailing Address - Fax:
Practice Address - Street 1:6256 VT ROUTE 30
Practice Address - Street 2:
Practice Address - City:PAWLET
Practice Address - State:VT
Practice Address - Zip Code:05761-9603
Practice Address - Country:US
Practice Address - Phone:802-325-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT091-106171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist