Provider Demographics
NPI:1508977091
Name:BEVERSDORF, MAUREEN G (CPHT)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:G
Last Name:BEVERSDORF
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21960 LESTER ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-1736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131 KERCHEVAL AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3629
Practice Address - Country:US
Practice Address - Phone:313-640-2591
Practice Address - Fax:313-640-2589
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI221507051552616183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI221507051552616OtherPHARM CERTIFIED TECH