Provider Demographics
NPI:1548388143
Name:HANES, BEVERLY (MA MFT)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:
Last Name:HANES
Suffix:
Gender:F
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 52974
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92517-3974
Mailing Address - Country:US
Mailing Address - Phone:951-334-3177
Mailing Address - Fax:909-424-0222
Practice Address - Street 1:1420 E COOLEY DR
Practice Address - Street 2:SUITE 200 S
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3981
Practice Address - Country:US
Practice Address - Phone:951-334-3177
Practice Address - Fax:909-424-0222
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40326106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33BGJ3OtherRIVERSIDE CO MEDICAL