Provider Demographics
NPI:1467935478
Name:BEAVER, LYNN L
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:L
Last Name:BEAVER
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 1:164 STATE HIGHWAY 83
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32433-7428
Mailing Address - Country:US
Mailing Address - Phone:850-902-9445
Mailing Address - Fax:850-373-4906
Practice Address - Street 1:164 STATE HIGHWAY 83
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-7428
Practice Address - Country:US
Practice Address - Phone:850-902-9445
Practice Address - Fax:850-373-4906
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLS-2400320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities