Provider Demographics
NPI:1508094046
Name:PARKS, BEVERLY S (LGSW)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:S
Last Name:PARKS
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2336 GODDARD PKWY
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-1126
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:410-334-6960
Practice Address - Street 1:2336 GODDARD PKWY
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-1126
Practice Address - Country:US
Practice Address - Phone:410-334-6961
Practice Address - Fax:410-334-6960
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG11569104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD499188OtherVO-MHA
MD609550001Medicaid